A 7-year-old girl presented to the emergency room with an avulsed segment of her right upper lip after a dog bite. The patient’s injury extended from the ipsilateral philtral column, across the right nasal sill and alar base to include the white roll and dry vermilion, with lateral extension to the nasolabial fold. Intraoperatively, the amputated segment was noted to have an intact vessel. The vessel was identified as a branch of the facial vein at the level of the nasolabial fold (Fig. 1). There was no accompanying artery in the avulsed segment. After 9 hours of cold ischemia time, we decided to proceed with revascularization using an artery-to-vein anastomosis with inflow through the superior labial artery. The avulsed segment was successfully revascularized and the lateral inset left open to avoid pedicle compression caused by postoperative edema. The patient was placed on a heparin drip and acetylsalicylic acid therapy for anticoagulation, and leech therapy was started immediately. She remained intubated while undergoing leech therapy, and the tissue was monitored for venous congestion. Postoperatively, the patient required 10 pediatric blood units. On postoperative day 8, leeching therapy was stopped and the patient was extubated. The patient was discharged on postoperative day 15 and returned 2 weeks after discharge for revision and inset of the lateral portion of the flap.
Although facial injuries are commonplace for plastic surgeons, lip amputation is an unusual injury and can pose a difficult challenge to the reconstructive surgeon. Replantation of the amputated segment yields a superior functional and aesthetic result when compared with local reconstructive options.1,2 It has also been demonstrated that replantation can be successfully performed in the absence of usable veins with an artery-only anastomosis with venous outflow provided by leech therapy, topical heparin, chemical leeching, and systemic anticoagulation.2,3
In our case, we describe successful replantation of an avulsed upper lip segment using an arterialized venous anastomosis. Blood flow through the attached superior labial vein was in a retrograde direction. Although valves have been identified in both facial and angular veins and its tributaries,4,5 we are uncertain whether valves were present in the vein at this level; however, because of successful inflow, we are led to believe that valves were not present or were merely incompetent in the face of arterial inflow. To prevent compression of the vein in the setting of postoperative edema, we elected to delay inset of the lateral portion of the flap overlying the vein. This has been described previously in cases in which the replanted segment demonstrated intraoperative compromise to arterial flow or venous congestion.3 In the case of artery-to-vein anastomosis, we would recommend partial inset to avoid vascular compromise.
Venous congestion was circumvented using medicinal leeches and anticoagulation therapy. This was continued until the flap underwent neovascularization and demonstrated independence from leeching on postoperative day 8. Such a time course has been well supported in the published literature in cases where efferent flow was absent.1-3 Use of this protocol resulted in an aesthetically acceptable outcome with nearly normal function (Fig. 2).
Parents or guardians provided written consent for use of the patient’s images.
The authors have no financial interest to declare in relation to the content of this article.
Russell G. Hendrick, Jr., M.D.
Pankaj Tiwari, M.D.
Department of Plastic Surgery
Wexner Medical Center at The Ohio State University
1. Duroure F, Simon E, Fadhul S, Fyad JP, Chassagne JF, Stricker M. Microsurgical lip replantation: Evaluation of functional and aesthetic results of three cases. Microsurgery. 2004;24:265–269
2. Walton RL, Beahm EK, Brown RE. Microsurgical replantation of the lip: A multi-institutional experience. Plast Reconstr Surg.. 1998;102:358–368
3. Taylor HO, Andrews B. Lip replantation and delayed inset after a dog bite: A case report and literature review. Microsurgery. 2009;29:657–661
4. Nishihara J, Takeuchi Y, Miki T, Itoh M, Nagahata S. Anatomical study on valves of human facial veins. J Craniomaxillofac Surg.. 1995;23:182–186
5. Zhang J, Stringer M. Ophthalmic and facial veins are not valveless. Clin Experiment Ophthalmol.. 2010;38:502–510