A 72-year-old woman had squamous cell carcinoma of the lower lip. The tumor was resected to leave an intact margin at least 1 cm away from the tumor border. A defect involving two thirds of the lower lip was created (Figure 1). How would you repair this defect?
Resolution of the Conundrum
A mental V–Y island advancement flap was designed according to the shape of the defect, with the apex lying inferiorly and incorporating the mental nerve. The base of the triangle abutted the inferior border of the excision, and the apex lay below the mandibular edge. After skin incision on the planned borders of the V–Y flap, the flap was elevated from the bone in a medial to lateral direction after deepening the medial incision to the periosteum. Careful attention was paid to preserve the integrity of the mental neurovascular bundle. The mandibular attachments of the depressor muscles were separated from the bone while elevating the flap apex; next, the dissection was conducted superiorly at the lateral border, leaving the orbicularis oris and depressor anguli oris muscles intact, although their attachments to the bone had already been separated. Thus, a mental V–Y island advancement flap was created and advanced superomedially. The base of the triangle that abutted onto the inferior border of the excision was de-epithelialized to a width of approximately 1 cm for restoration of the volume of the resected lip. Mucosal coverage was provided by a mucosal graft. For this purpose, the authors harvested buccal mucosa from the side of the oral cavity. The mucosal graft included only mucosa for a high survival rate. The donor site was closed primarily. The tie-over dressing was placed and then removed from the recipient site after 3 days. After 6 months, the functional and aesthetic results were good (Figure 2). No recurrence was observed after 18 months.
Discussion of Considerations
In this case, the lower lip defect was wide and involved both the cutaneous layer and mucosa of the lip. A particular problem was the large defect of the lip mucosa. For successful restoration, mucosal resurfacing was needed. Furthermore, it was important to consider volume augmentation.
The challenge in lower lip reconstruction after ablative surgery is preserving function while producing the best aesthetic results possible. Although full-thickness defects less than one third of the length of the lower lip can be reconstructed by simple primary closure, various types of flap procedures have been described to permit the reconstruction of larger defects.1 Nevertheless, functional and aesthetic preservation is difficult for large lower lip defects.
The mucosal layer can be reconstructed by advancement flaps, cross-lip flaps, tongue flaps, or commissure-based buccal mucosa flaps. The advancement flap is a good option when the anterior–posterior dimension of the lip is adequate for flap elevation. However, it has potential disadvantages such as decrease in the anterior–posterior dimension of the lip. In addition, for large defects on the mucosal surface of the lip, this type of flap has limited applications. The upper lip and tongue provide sufficient donor site tissue for reconstructing a vermilion defect. These options are good when local flaps are not available. One disadvantage of the procedure is that it is necessary to maintain the upper lip and tongue attached to the lower lip for a period of 2 weeks, and the pedicle is then divided in the second surgical stage. The commissure-based buccal mucosa flap can cover defects of various sizes or locations. Modification of the flap, including large or bilateral flaps, may be applied depending on the size or location of the defect. However, a disadvantage of the procedure is that it causes distortion of the oral commissure. It is difficult to fix an already distorted oral commissure.2,3
The mental V–Y advancement flap is a useful reconstruction method for the cutaneous layer of the lower lip. The basis of the mental V–Y advancement flap is the simple advancement of tissues from both sides of the chin as myocutaneous flaps that are pulled upward toward the lip defect and reorientation of the muscles of the flap for sphincteric function while preserving the mental nerve for sensation. Soft tissues over the mentum are not disturbed and are preserved as an intact unit. The lateral muscle attachments with their vascular and nerve supplies are preserved, ensuring muscular continuity and function. The lateral attachments of these muscles are bluntly separated from the overlying skin and underlying mandible and mucosa; thus, lip sensation and motor function are not affected.2 In addition, this procedure can easily restore the lip volume with the de-epithelialized base of a triangular flap. It can cover defects involving more than one third of the lower lip. If a flap is elevated bilaterally, even a total defect of the lower lip can be restored. However, this procedure is inappropriate when less than half of the vertical dimension of the chin remains.
The mucosal graft effectively restores the lip mucosa, especially in patients with large defects that cannot be covered by local flaps, such as advancement flaps. The mucosal graft with a hard palate has been reported.4 The authors have used the mucosa from the buccal side of the oral cavity as a mucosal graft. The characteristics of the buccal mucosa are more similar to those of the lip than the palatal mucosa. The donor site is closed primarily so that the procedure creates less pain and is simpler to manage postoperatively. Thus, the authors believe that the buccal mucosa graft is a good option for reconstruction of large defects of the lip mucosa. In some cases, reconstruction is difficult using a simple local flap such as an advancement flap, but the buccal mucosal graft is a good choice for mucosal lip reconstruction.
In this case, the lip reconstruction involved reconstruction of both the cutaneous and mucosal layers of the lip. The mental V–Y advancement flap is a useful reconstruction method for the cutaneous lower lip. In addition, it can restore lip volume without any difficulties. The buccal mucosa graft is also a good option for reconstruction of large defects of the lip mucosa.
1. Closmann JJ, Pogrel MA, Schmidt BL. Reconstruction of perioral defects following resection for oral squamous cell carcinoma. J Oral Maxillofac Surg 2006;64:367–74.
2. Bayramicli M, Numanoglu A, Tezel E. The mental V-Y island advancement flap in functional lower lip reconstruction. Plastic Reconstr Surg 1997;100:1682–90.
3. Sand M, Altmeyer P, Bechara FG. Mucosal advancement flap versus primary closure after vermilionectomy of the lower lip. Dermatol Surg 2010;36:1987–92.
4. Ito R, Fujiwara M. Lower lip reconstruction with a hard palate mucoperiosteal graft. J Plast Reconstr Aesthet Surg 2009;62:e333–6.