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The inferior labial artery island flap
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e294ee297
CASE REPORT
The inferior labial artery island flap Koichiro Oki, Rei Ogawa*, Feng Lu, Hiko Hyakusoku Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, 1-1-5 Sendagi Bunkyo-ku, Tokyo, Japan Received 25 February 2007; accepted 15 September 2007
KEYWORDS Inferior labial flap; Labial artery flap; Abbe flap; Upper lip reconstruction
Summary The Abbe flap procedure has typically been indicated in cases of tissue defects of the upper lip after injury or tumour excision. However, this method requires two-stage reconstruction. In this report, we describe for the first time a novel one-stage reconstruction method using the inferior labial artery island flap. A 54-year-old man presented with a left upper lip defect and a scar contracture between the upper lip and the left cheek. We planned to reconstruct the lip defect using the inferior labial artery island flap. The inferior labial artery island flap was harvested with a vascular pedicle, and the vascular pedicle was returned through the inside of the flap. The flap survived completely, and liquid leakage from the lip and the appearance of the injured area were clearly improved. For this new technique, we converted the inferior labial flap to a vascular pedicled island flap, which increased its flexibility. This long vascular pedicle could be returned through the inside of the flap. Thus, this flap appears to be ideal for one-stage reconstructions of full-thickness upper lip defects. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The Abbe flap1 procedure is usually indicated in cases of tissue defects of the upper lip after injury or tumour excision, but it requires two-stage reconstruction. In this report, we describe for the first time a novel one-stage reconstruction using the inferior labial artery island flap. The inferior labial artery island flap is harvested with a vascular pedicle, and the vascular pedicle is returned through the inside of the flap (Figure 1). This technique is ideal for one-stage reconstructions of full-thickness upper lip defects. * Corresponding author. Tel.: þ81 3 5814 6208; fax: þ81 5685 3076. E-mail address: [email protected] (R. Ogawa).
Case report A 54-year-old man presented with a left upper lip defect and a scar contracture between the upper lip and the left cheek, which resulted from an avulsion injury due to a motor vehicle accident. The lip defect caused liquid leakage from the mouth. Thus, we planned to reconstruct the lip defect using the inferior labial artery island flap. Doppler flowmetry was used to mark the course of the labial artery preoperatively (Figure 2). A 12-mm wide flap was designed centrally on the lower lip, including not only the mucosa but also skin and the orbicularis oris muscle, and was cut down to the mentolabial fold. The inferior labial artery was found in a facial compartment on the
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.2007.09.062
The inferior labial artery island flap
e295
Figure 1 Schema of the upper lip reconstruction using the inferior labial island flap. In this technique, the long vascular pedicle can be returned through the inside of the flap.
posterior part of the orbicularis oris muscle. The veins were more haphazardly arranged around the artery, in the loose tissue under the vermilion epithelium and in the intermuscular septa. The muscle cuff surrounding the labial vessels was then removed by careful dissection and only the labial vessels were left embedded in the pedicle. After confirming the inferior labial vessels, the flap was completely elevated
with the pedicle, including one artery and two veins, of approximately 3 cm in length (Figure 3). After removal of the scar on the recipient site, the highly mobile flap resulting from this division could be inserted into the recipient site on the upper lip in one stage. The vermilion borders and thickness between the flap and upper lip could be adjusted in this stage. The vascular pedicle was buried under the vermilion mucosa without any tissue tightness. The vascular pedicle length was 3 cm, but we could confirm 6 mm of redundancy when the mouth was closed. This redundancy was useful for releasing tension when the mouth was open. The donor defect was closed primarily and the flap survived completely. At the 2 month follow-up, liquid leakage from the lip defect was improved. Dysfunction of the orbicularis oris muscle was not observed, and sensory function was recovered within 3 months. The patient was satisfied not only with the function but also with the appearance of his lip (Figure 4).
Discussion
Figure 2 Flap design. The flap was designed to include not only mucosa but also skin of the lower lip. Doppler ultrasound was used to mark the course of the labial artery preoperatively.
Abbe’s cross-lip flap, which was described in 1898,1 remains the method of choice for repair of upper lip defects, cleft lip deformity, and trauma or tumour resection around the lip. McGregor pointed out the importance of dividing all the skin of the Abbe flap and making the surface component of the pedicle entirely mucosal.2 Millard also emphasised the value of a narrow pedicle, but did not suggest completely severing the mucosa.3 In 1989, Holmstrom presented a technique in which the mucosa is cut around the whole circumference of the pedicle,4 essentially converting the Abbe flap to an island flap.
e296
Figure 3 Intraoperative view. After confirming the inferior labial vessels, the flap was completely elevated with a pedicle, including one artery and two veins, of approximately 3 cm in length.
On the other hand, a one-stage lip-switch operation for reconstructing a lip defect was reported by Ohtsuka in 1985.5 One-stage reconstruction of the lip is challenging because both lip function and acceptable aesthetic appearance must be simultaneously considered during repair. Ohtsuka pointed out the importance of the oral mucosal pedicle for the venous drainage of the flap. A minute venous network surrounding the artery in the vascular pedicle was thought to play an important role in venous drainage. In Ohtsuka’s procedure, the orbicularis oris muscle is not damaged during elevation of the pedicle, and the distal portion of the flap is incised a little closer to the mucous membrane to allow the de-epithelialised vascular pedicle to pass through it. Hu also reported a one-stage procedure involving an inferior labial flap with a mucosal pedicle in 1993.6 However, after this operation, venous drainage of the lip was compromised because no axial vein accompanied the labial artery. As a result of the slender pedicle, various degrees of venous congestion, and even necrosis of the Abbe flap, often occurred.
K. Oki et al. In contrast, the present technique involves cutting the skin and mucosa around the whole circumference of the vascular pedicle. Furthermore, the labial vessels, including one artery and two veins, were confirmed between the centre of the lower lip and the oral commissure. In this technique, the inferior labial flap was converted to a vascular pedicled island flap, which increases its flexibility. This long vascular pedicle could be returned through the inside of the flap, which had been divided between the vermilion mucosa and the orbicularis oris muscles. Accordingly, the vermilion border and white lip of the flap could be fitted to the defect of the upper lip in one stage. In 2001, Shulte reported that the course of the inferior labial artery varies up to 15 mm from the free margin of the lower lip.7 In 2003, Edizer also pointed out that this region does not have a constant arterial distribution; the inferior labial artery can have different unilateral or bilateral locations.8 However, in 2004, Kawai mentioned that the inferior labial artery was derived from the facial artery or superior labial artery, and the presence of this artery was confirmed in all the fresh cadavers evaluated for this purpose.9 We therefore suggest use of preoperative Doppler flowmetry to improve the safety associated with creating inferior labial artery flaps. Venous dissection of the vascular pedicle requires a delicate technique. In the present case, two veins, located in the submucosal tissue and intermuscular septa, were detected around the inferior labial artery. Otsuka and Song suggested that the venous plexus of the mucosal pedicle was important for the venous drainage of this flap; however, they had removed the orbicularis oris muscle.5,6 Nonetheless, we recommend that, if the labial veins are not confirmed during the vascular-pedicle elevation, the submucosal tissue and the orbicularis oris muscle cuff around the labial artery be preserved for venous drainage of this flap.4 Moreover, we could confirm that there was no dysfunction of the orbicularis oris muscle, and the recovery of sensory function was not different from that seen after a conventional Abbe flap. Further investigation is necessary to elucidate factors such as the venous drainage system. However, the inferior labial artery island flap appears to be ideal for one-stage reconstructions of full-thickness upper lip defects.
Figure 4 Preoperative and 2 month postoperative view. At the 2 month follow-up, liquid leakage from the lip defect was improved. The patient was satisfied with the function and appearance of his lip.
The inferior labial artery island flap
References 1. Abbe RA. A plastic operation for the relief of deformity due to double harelip. Med Rec 1898;531:477e8. 2. McGregor IA. The Abbe flap; its use in single and double lip clefts. Br J Plast Surg 1963;16:46e59. 3. Millard Jr DR, McLaughlin CA. Abbe flap on mucosal pedicle. Ann Plast Surg 1979;3:544e8. 4. Holmstrom H. The Abbe flap converted to an island flap. Scand J Plast Reconstr Surg 1986;20:51e4.
e297 5. Ohtsuka H. One-stage lip-switch operation. Plast Reconstr Surg 1985;76:613e5. 6. Hu H, Song R, Sun G. One-stage inferior labial flap and its pertinent anatomic study. Plast Reconstr Surg 1993;91:618e23. 7. Schulte DL, Sherris DA, Kasperbauer JL. The anatomical basis of the Abbe flap. Laryngoscope 2001;111:382e6. 8. Edizer M, Magden O, Tayfur V, et al. Arterial anatomy of the lower lip: a cadaveric study. Plast Reconstr Surg 2003;111:2176e81. 9. Kawai K, Imanishi N, Nakajima H, et al. Arterial anatomy of the lower lip. Scand J Plast Reconstr Surg Hand Surg 2004;38:135e9.
CASE REPORT
The inferior labial artery island flap Koichiro Oki, Rei Ogawa*, Feng Lu, Hiko Hyakusoku Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, 1-1-5 Sendagi Bunkyo-ku, Tokyo, Japan Received 25 February 2007; accepted 15 September 2007
KEYWORDS Inferior labial flap; Labial artery flap; Abbe flap; Upper lip reconstruction
Summary The Abbe flap procedure has typically been indicated in cases of tissue defects of the upper lip after injury or tumour excision. However, this method requires two-stage reconstruction. In this report, we describe for the first time a novel one-stage reconstruction method using the inferior labial artery island flap. A 54-year-old man presented with a left upper lip defect and a scar contracture between the upper lip and the left cheek. We planned to reconstruct the lip defect using the inferior labial artery island flap. The inferior labial artery island flap was harvested with a vascular pedicle, and the vascular pedicle was returned through the inside of the flap. The flap survived completely, and liquid leakage from the lip and the appearance of the injured area were clearly improved. For this new technique, we converted the inferior labial flap to a vascular pedicled island flap, which increased its flexibility. This long vascular pedicle could be returned through the inside of the flap. Thus, this flap appears to be ideal for one-stage reconstructions of full-thickness upper lip defects. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The Abbe flap1 procedure is usually indicated in cases of tissue defects of the upper lip after injury or tumour excision, but it requires two-stage reconstruction. In this report, we describe for the first time a novel one-stage reconstruction using the inferior labial artery island flap. The inferior labial artery island flap is harvested with a vascular pedicle, and the vascular pedicle is returned through the inside of the flap (Figure 1). This technique is ideal for one-stage reconstructions of full-thickness upper lip defects. * Corresponding author. Tel.: þ81 3 5814 6208; fax: þ81 5685 3076. E-mail address: [email protected] (R. Ogawa).
Case report A 54-year-old man presented with a left upper lip defect and a scar contracture between the upper lip and the left cheek, which resulted from an avulsion injury due to a motor vehicle accident. The lip defect caused liquid leakage from the mouth. Thus, we planned to reconstruct the lip defect using the inferior labial artery island flap. Doppler flowmetry was used to mark the course of the labial artery preoperatively (Figure 2). A 12-mm wide flap was designed centrally on the lower lip, including not only the mucosa but also skin and the orbicularis oris muscle, and was cut down to the mentolabial fold. The inferior labial artery was found in a facial compartment on the
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.2007.09.062
The inferior labial artery island flap
e295
Figure 1 Schema of the upper lip reconstruction using the inferior labial island flap. In this technique, the long vascular pedicle can be returned through the inside of the flap.
posterior part of the orbicularis oris muscle. The veins were more haphazardly arranged around the artery, in the loose tissue under the vermilion epithelium and in the intermuscular septa. The muscle cuff surrounding the labial vessels was then removed by careful dissection and only the labial vessels were left embedded in the pedicle. After confirming the inferior labial vessels, the flap was completely elevated
with the pedicle, including one artery and two veins, of approximately 3 cm in length (Figure 3). After removal of the scar on the recipient site, the highly mobile flap resulting from this division could be inserted into the recipient site on the upper lip in one stage. The vermilion borders and thickness between the flap and upper lip could be adjusted in this stage. The vascular pedicle was buried under the vermilion mucosa without any tissue tightness. The vascular pedicle length was 3 cm, but we could confirm 6 mm of redundancy when the mouth was closed. This redundancy was useful for releasing tension when the mouth was open. The donor defect was closed primarily and the flap survived completely. At the 2 month follow-up, liquid leakage from the lip defect was improved. Dysfunction of the orbicularis oris muscle was not observed, and sensory function was recovered within 3 months. The patient was satisfied not only with the function but also with the appearance of his lip (Figure 4).
Discussion
Figure 2 Flap design. The flap was designed to include not only mucosa but also skin of the lower lip. Doppler ultrasound was used to mark the course of the labial artery preoperatively.
Abbe’s cross-lip flap, which was described in 1898,1 remains the method of choice for repair of upper lip defects, cleft lip deformity, and trauma or tumour resection around the lip. McGregor pointed out the importance of dividing all the skin of the Abbe flap and making the surface component of the pedicle entirely mucosal.2 Millard also emphasised the value of a narrow pedicle, but did not suggest completely severing the mucosa.3 In 1989, Holmstrom presented a technique in which the mucosa is cut around the whole circumference of the pedicle,4 essentially converting the Abbe flap to an island flap.
e296
Figure 3 Intraoperative view. After confirming the inferior labial vessels, the flap was completely elevated with a pedicle, including one artery and two veins, of approximately 3 cm in length.
On the other hand, a one-stage lip-switch operation for reconstructing a lip defect was reported by Ohtsuka in 1985.5 One-stage reconstruction of the lip is challenging because both lip function and acceptable aesthetic appearance must be simultaneously considered during repair. Ohtsuka pointed out the importance of the oral mucosal pedicle for the venous drainage of the flap. A minute venous network surrounding the artery in the vascular pedicle was thought to play an important role in venous drainage. In Ohtsuka’s procedure, the orbicularis oris muscle is not damaged during elevation of the pedicle, and the distal portion of the flap is incised a little closer to the mucous membrane to allow the de-epithelialised vascular pedicle to pass through it. Hu also reported a one-stage procedure involving an inferior labial flap with a mucosal pedicle in 1993.6 However, after this operation, venous drainage of the lip was compromised because no axial vein accompanied the labial artery. As a result of the slender pedicle, various degrees of venous congestion, and even necrosis of the Abbe flap, often occurred.
K. Oki et al. In contrast, the present technique involves cutting the skin and mucosa around the whole circumference of the vascular pedicle. Furthermore, the labial vessels, including one artery and two veins, were confirmed between the centre of the lower lip and the oral commissure. In this technique, the inferior labial flap was converted to a vascular pedicled island flap, which increases its flexibility. This long vascular pedicle could be returned through the inside of the flap, which had been divided between the vermilion mucosa and the orbicularis oris muscles. Accordingly, the vermilion border and white lip of the flap could be fitted to the defect of the upper lip in one stage. In 2001, Shulte reported that the course of the inferior labial artery varies up to 15 mm from the free margin of the lower lip.7 In 2003, Edizer also pointed out that this region does not have a constant arterial distribution; the inferior labial artery can have different unilateral or bilateral locations.8 However, in 2004, Kawai mentioned that the inferior labial artery was derived from the facial artery or superior labial artery, and the presence of this artery was confirmed in all the fresh cadavers evaluated for this purpose.9 We therefore suggest use of preoperative Doppler flowmetry to improve the safety associated with creating inferior labial artery flaps. Venous dissection of the vascular pedicle requires a delicate technique. In the present case, two veins, located in the submucosal tissue and intermuscular septa, were detected around the inferior labial artery. Otsuka and Song suggested that the venous plexus of the mucosal pedicle was important for the venous drainage of this flap; however, they had removed the orbicularis oris muscle.5,6 Nonetheless, we recommend that, if the labial veins are not confirmed during the vascular-pedicle elevation, the submucosal tissue and the orbicularis oris muscle cuff around the labial artery be preserved for venous drainage of this flap.4 Moreover, we could confirm that there was no dysfunction of the orbicularis oris muscle, and the recovery of sensory function was not different from that seen after a conventional Abbe flap. Further investigation is necessary to elucidate factors such as the venous drainage system. However, the inferior labial artery island flap appears to be ideal for one-stage reconstructions of full-thickness upper lip defects.
Figure 4 Preoperative and 2 month postoperative view. At the 2 month follow-up, liquid leakage from the lip defect was improved. The patient was satisfied with the function and appearance of his lip.
The inferior labial artery island flap
References 1. Abbe RA. A plastic operation for the relief of deformity due to double harelip. Med Rec 1898;531:477e8. 2. McGregor IA. The Abbe flap; its use in single and double lip clefts. Br J Plast Surg 1963;16:46e59. 3. Millard Jr DR, McLaughlin CA. Abbe flap on mucosal pedicle. Ann Plast Surg 1979;3:544e8. 4. Holmstrom H. The Abbe flap converted to an island flap. Scand J Plast Reconstr Surg 1986;20:51e4.
e297 5. Ohtsuka H. One-stage lip-switch operation. Plast Reconstr Surg 1985;76:613e5. 6. Hu H, Song R, Sun G. One-stage inferior labial flap and its pertinent anatomic study. Plast Reconstr Surg 1993;91:618e23. 7. Schulte DL, Sherris DA, Kasperbauer JL. The anatomical basis of the Abbe flap. Laryngoscope 2001;111:382e6. 8. Edizer M, Magden O, Tayfur V, et al. Arterial anatomy of the lower lip: a cadaveric study. Plast Reconstr Surg 2003;111:2176e81. 9. Kawai K, Imanishi N, Nakajima H, et al. Arterial anatomy of the lower lip. Scand J Plast Reconstr Surg Hand Surg 2004;38:135e9.