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Modified Bilateral Neurovascular Cheek Flap: Functional Reconstruction of Extensive Lower Lip Defects

Chowchuen, Bowornsilp MD, MBA

Plastic and Reconstructive Surgery – Global Open: May 2016 - Volume 4 - Issue 5 - p e721
doi: 10.1097/GOX.0000000000000680
Original Article
Open
Thailand
Best Paper

Background: Reconstruction of extensive lower lip defects is challenging, and functional outcomes are difficult to achieve.

Methods: A modified bilateral neurovascular cheek (MBNC) flap has been described. The data of patients with cancer of the lower lip treated with wide excision and reconstructed with the MBNC flap in the Plastic Surgery Unit, Srinagarind Hospital, Khon Kaen University, from 1966 to 2012 were reviewed.

Results: Of the total of 143 patients included, 90.91% were women, and their age ranged from 32 to 100 years. All defects involved 70% or greater of the lower lip, which included oral commissure, buccal mucosa, or cheek skin and upper lip. All 20 patients who were followed up demonstrated good outcomes of intercommissural distance, interlabial distance, sulcus depth, and 2-point discrimination compared with normal lip parameters according to age group and satisfaction with treatment.

Conclusions: Reconstruction of extensive lower lip defects with the MBNC flap provided good oral competence and functional outcomes. The flap provided adequate lip height and width, with proper position of oral commissure and vermilion reconstruction. The awareness about neurovascular anatomy of the lip and cheek and gentle dissection preserve the lip function. The flap overcomes the drawbacks of Karapandzic technique, which is microstomia, and of Bernard technique, which is a tight adynamic lower lip. It can be used in defects of more than two-thirds of the lip, extending to the cheek, commissural reconstruction, and secondary reconstruction.

From the Faculty of Medicine, Division of Plastic Surgery, Department of Surgery, Khon Kaen University, Khon Kaen, Thailand.

Received for publication April 3, 2015; accepted February 23, 2016.

Disclosure: The author has no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the author.

Bowornsilp Chowchuen, MD, MBA, Faculty of Medicine, Division of Plastic Surgery, Department of Surgery, Khon Kaen University, Mitraparb Road, Khon Kaen 40002, Thailand, E-mail: bowcho@kku.ac.th

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

A study of carcinoma of the lips in Srinagarind Hospital, Khon Kaen University, showed the female to male ratio to be 7.2:1; 14, 25, 21, and 15 cases in stage I, II, III, and IV, respectively; and the ratio of the lower lip to the upper lip to be 5.4:1.1 Challenges in reconstructing large lower lip defects include restoring good sensation, preserving sphincter or muscle function, opposing vermilion to vermilion of the opposite lips, creating a watertight seal, providing sufficient opening for food and dentures, and being aesthetically pleasing.2,3 The majority of described techniques cannot meet the requirements of functional lip, good oral competence, and prevention of microstomia.4

A neurovascular cheek flap has been described as a unilateral flap by McHugh5 and a bilateral flap by Vatanasapt et al.6 The author (B.C.) has described a modified bilateral neurovascular cheek (MBNC) flap for lower lip reconstruction7,8 and upper lip reconstruction,9,10 with flap details to preserve neurovascular structure and the addition of rectangular flaps to the base of the triangular flap.

This study aimed to present design and outcomes of the MBNC flap for reconstruction of various extensive lower lip defects.

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PATIENTS AND METHODS

The clinical records of patients with cancer of the lower lip reconstructed with the MBNC flap in the Plastic Surgery Unit, Srinagarind Hospital, Khon Kaen University, from 1966 to 2012 were reviewed.

The outcomes included the intercommissural distance (ICD; the distance between the commissures measured while a patient is swallowing), the interlabial distance (ILD; the straight line between the wet–dry line in the center of the upper lip and the lower lip when the mouth is widely opened), the sulcus depth (SD; the distance between the bottom of the labiogingival sulcus and the wet–dry line of the vermilion), the lip sensitivity [the 2-point discrimination test (2PD)],11,12 and patient’s satisfaction.

The protocol was approved by the ethics committee of Khon Kaen University.

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OPERATIVE TECHNIQUE

Details of the MBNC flap have been described,8 such as designing the lower line of resection parallel to the vermilion border, avoiding an incision below the mental crease, and designing the part of the mucosal flap slightly higher than the commissure for resurfacing the vermilion (Fig. 1A, B). Figure 1C and D shows the final closure of the skin and mucosal flaps. Figure 2 shows intraoperative techniques of the MBNC flap.

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

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RESULTS

Of the 143 patients included in the study, 130 were women (90.91%) and 13 were men (9.09%), and their ages ranged from 32 to 100 years (average age, 69 years). The size of tumor ranged from 2.5 to 6 cm. All defects included 70% or more of a lower lip and oral commissure, buccal mucosa, cheek skin, and upper lip. There were 9 patients with a recurrent tumor, and 10 patients received preoperative radiation treatment (6.99%).

There were no immediate complications, ie, bleeding and infection, except 1 patient with wound dehiscence, which required resuturing. One patient presented with a 6-cm recurrent tumor of the lower lip after excision with the Estlander flap, and a total lower lip reconstruction was performed. There was a slight limitation of mouth opening, which was improved without additional surgery. Another patient presented with 4.5-cm lesions, and a total lower lip reconstruction was performed. There was a minimal narrow oral commissure, and a commissuroplasty was later performed 3 months after operation. No patient required scar revision. Nineteen patients had recurrent tumors and additional surgery, such as surgical excision and neck dissection. Twenty-five patients (17.48%) received postoperative radiation treatment.

Twenty patients were followed up for outcome measures with a range of 6 to 132 months [mean, 53.35 months (±40.44)]. The defect size and comparable functional outcomes of ICD, SD, ILD, and 2PD to normal lip parameters according to different age groups are described in Table 1.

Table 1.

Table 1.

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Reconstruction of Total Lower Lip Defects

A female patient, aged 74 years, presented with multiple ulcerative masses of lower lip cancer and underwent a wide excision and reconstruction with the MBNC flap and postoperative radiation therapy. At 31 months after operation, she was very satisfied with her appearance and has good functional lips (Fig. 3). The ICD, ILD, SD, and 2PD were 55, 52, 21, and 2 mm, respectively.

Fig. 3.

Fig. 3.

A female patient, aged 74 years, presented with a 4-cm lower lip lesion, and underwent a wide excision and a total lip reconstruction with the MBNC flap. At 14 months after operation, the ICD, ILD, SD, and 2PD were 62, 50, 28, and 2 mm, respectively. The patient had satisfactory appearance (Fig. 4).

Fig. 4.

Fig. 4.

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Reconstruction of Defects Larger Than a Total Lip Defect

An 83-year-old female patient presented with a lower lip lesion sized 5 cm, involving oral commissure, and underwent a wide excision of lip, commissure, and right cheek and a reconstruction with the MBNC flap. At 39 months after operation, she was very satisfied with her lips (Fig. 5). The ICD, ILD, SD, and 2PD were 63, 42, 24, and 2 mm, respectively.

Fig. 5.

Fig. 5.

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Reconstruction of Recurrent Cancer of a Lower Lip

A 66-year-old woman presented with recurrent carcinoma involving almost the entire lower lip after the Karapandzic fan flap reconstruction13 5 years ago and underwent resection and total lip reconstruction with the MBNC flap. At 6 months after operation, the ICD, ILD, SD, and 2PD were 47, 35, 16, and 1 mm, respectively. The scar was acceptable with good oral competence (Fig. 6).

Fig. 6.

Fig. 6.

The measurement of lip function was also performed in 201 Thai volunteers (101 women and 100 men). The results of this study will be reported in another article.

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DISCUSSION

A previous study reported that carcinoma of the lip in the Thai population predominantly occurred in women because of the habit of chewing betel nut and working outdoors.1

The primary goal of lip reconstruction is a functional lip with good oral competence, which can be achieved if the sphincter is reconstructed and sensation preserved.14 The local tissue provides color and texture match, tissue with similar thickness, and skin and mucosal tissue characteristics.15 Various techniques have been proposed,16,17 but total or near-total defects of the lip pose challenges of a poor aesthetic outcome and compromised oral competence. The Karapandzic flap provides lip competence with a sensate, mobile lip, but its primary drawback is microstomia.14,18 Bernard's19 technique uses transposition of full-thickness flaps and requires the excision of 3 cutaneous triangles. Although microstomia can be avoided, there is no functional orbicularis with a tight adynamic lower lip because of denervation.18 Many reconstructive techniques do not provide mucosal replacement of lip vermilion. The free flap techniques produce less cosmetic and functional results.20

The MBNC provides adequate lip height with muscular part by the rectangular flap added to the base of the triangular flap. The mental crease defines the inferior margin of the flap.15 Injury to the parotid duct ampulla is avoided by preserving it outside or inside the flap. The flap design incorporates the remaining lower lip, the orbicularis oris muscle, which forms a sphincteric ring around the mouth15 and cheek musculature. A full-thickness incision was made at the medial edge of the skin and mucosal flap with preservation of branches of arterial supply to the lower lip and was not made lateral to the facial artery. The lateral incision was deep to subcutaneous and submucosal tissue with blunt dissection of subcutaneous and cheek muscular tissue to preserve neurovascular structure, the major depressor muscles of lip15 and the buccinators21 and to allow better advancement of lower lip flaps. For adequate lip width and preservation of original position of the oral commissure, the modiolus is reconstructed by suturing muscle of the flap to the muscle of the upper lip just lateral to the commissure. The buccal and mandibular branches of the facial nerves leave the parotid near the parotid-masseteric fascia in the same plane as the parotid duct22 to supply the orbicularis oris, buccinators, and lip depressors. Branches of the maxillary and mandibular divisions of the trigeminal nerve for sensation to the lower lip are preserved by careful blunt dissection. The lateral edge of the skin and mucosal flaps are approximated using a V-Y technique.10 The designed mucosa in the mucosal flap above the oral commissure is used to reconstruct the red vermilion.

The facial artery hooks around the lower border of the mandible at the anterior edge of the masseter muscle and passes upward and forward to near the oral commissure.23 The inferior labial artery and horizontal labiomental artery (HLA) are the main arteries of the MBNC flap.24,25 Their location, course, and dimensions of the lower lip are not constant.26 Knowledge about their location is important to avoid complications.27 The HLA branches from the facial artery in the middle of the lower lip and the inferior labial artery branches at the level of the oral commissure. In most cases, the HLA runs under the depressor anguli oris muscle and passes through the depressor labii inferioris and orbicularis oris muscles28,29 and can be preserved in the lower lip inferior to the oral commissure, and inclined gradually toward the lower lip. Careful dissection with precaution of variance in anatomical landmark will assure flap viability and avoid injury to these vessels. A number of facial artery perforators located predominantly at the level of the oral commissure are preserved in the flap and can be used as a pedicle flap.30

The MBNC flap resolves the challenges of aesthetic outcomes and provision of good oral competence with a sensate and mobile lip. The functional outcome was comparable with normal lip parameters described in a study.11 The flap preserved neurovascular tissue similar to the Karapandzic flap,14 but it overcomes microstomia, the limitation of the Karapandzic flap caused by change of position of the oral commissure.14,15,18 The flap overcomes the limitations of Webster-Bernard’s technique,19 which are chronic tension of closure and a tight adynamic lip.15,18 When the lip defect extends to a large portion of cheek or buccal mucosa, there may not be enough local tissues to use the MBNC flap.

The limitations of this retrospective study are as follows: patient records collected were for a long period of time (over decades), difficulty of the long-term follow-ups, economy, and death of a number of patients or recurrent tumors in many because of the advanced stage.

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CONCLUSIONs

Good functional and aesthetic outcomes and patient satisfaction support clinical applications of the MBNC flap. It can be used in extensive lower lip defects, such as defects of more than two-thirds of the lip, defects extending to the cheek, commissural reconstruction, both upper and lower lip reconstruction, and the secondary reconstruction of various difficult lip defects. With the recent modification, the cheek incision will be placed along the natural skin crease and provides a better scar.

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ACKNOWLEDGMENTS

The author thanks Dr. Radhakrishnan Muthukumar for assistance with English language presentation, Mr. Songpol Oopachitakul for illustration, Dr. Pattana Ongkasuwan for assistance of clinical data, and support from the Center of Cleft Lip-Palate and Craniofacial Deformities (Tawanchai Center), Khon Kaen University.

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PATIENT CONSENT

The patient in figure 6 provided written consent for the use of her image.

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