reconstruction of the lip commissure with upper … of the lip commissure with upper and lower lip...

Case Report

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For citation purposes: Elzahaby IA, Mohammed OH, Hafez MT, Abd Elaziz SR, Mosbah MM, Refky BA, et al. Reconstruction of the lip commissure with upper and lower lip full-thickness defects using submental and nasolabial flaps: a case report. Annals of Oral & Maxillofacial Surgery 2013 Oct 13;1(3):27. Com

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Reconstruction of the lip commissure with upper and lower lip full-thickness defects using submental and

nasolabial flaps: a case reportIA Elzahaby*, OH Mohammed, MT Hafez, SR Abd Elaziz, MM Mosbah, BA Refky, MT Abd Elmonem

buccal mucosa, preoperative wedge biopsy revealed an invasive grade II squamous cell carcinoma. The lesion was surgically removed followed by a supraomohyoid neck dissection. This was followed by the neck dissection. Reconstruction of the resultant large full-thickness defect was done using two pedicled flaps, namely the nasol-abial and submental island flaps. The histological examination of the speci-men (paraffin sections) confirmed the initial biopsy, which had revealed invasive grade II squamous cell car-cinoma. The excision margins were disease free as confirmed by the intra-operative frozen section examination, the right submandibular gland and all the right cervical lymph nodes dis-sected were free from tumour tissue except one submental lymph node.ConclusionThe reconstruction of this extensive tissue defect with the use of com-bined nasolabial and submental island flap was secure, reliable and produced satisfactory aesthetic and functional results. In our study, we didn’t find much interference with neck dissection during harvest of the submental island flap. Moreover, it is a single stage procedure without the need for a second stage for flap divi-sion and without causing significant narrowing of the mouth and the need for further surgical intervention for rewidening it.

IntroductionLip carcinoma is considered the most common oral cavity malignancy, rep-resenting about 30% of all oral cavity malignancies1.

Lips are special structures of the face and play an important role in food intake, communication, expres-sion of feelings, moreover they are also an important part of an individ-ual’s phenotypic traits2.

The treatment of lip carcinomas is mainly by surgical removal, and less frequently by radiotherapy or a com-bination of these two methods3,4,5.

Surgical excision of larger lesions of the lips and/or oral cavity usually creates two dimensional or three dimensional defects. The reconstruc-tion of such defects is technically challenging and has a significant effect on the quality of life6.

Local flaps such as Karapandzic flaps and Estandler flaps are often not sufficient and also regional flaps as pectorals major myocutaneous flap and deltopectoral flap have the disadvantages of being too bulky, have a limited reach and may require a second session for refashioning and division of the pedicle.

In recent years, the only satisfac-tory method of reconstruction of such extensive defects is the use of free vascular flaps such as radial forearm or anterolateral thigh flap, however. microvascular free flap techniques are technically complex7,8,9,10.

In this case, we describe the results of reconstructing a commisure defect extending to adjoining parts of both lips and inner buccal mucosa using extended superiorly based nasola-bial flap and submental flap.

Case report A 49-year-old male patient pre-sented in June 2011, with a large

AbstractIntroductionLip carcinoma is considered the most common oral cavity malignancy, rep-resenting about 30% of all oral cav-ity malignancies. The treatment of lip carcinomas is mainly by surgical removal, and less frequently by radio-therapy or a combination of these two methods. Surgical excision of larger lesions of the lips and/or oral cavity usually creates a two dimensional or three dimensional defects. The recon-struction of such defects is technically challenging. Local flaps are often not sufficient and also regional flaps have the disadvantages of being too bulky, have a limited reach and may require a second session for refashioning and division of the pedicle. The only sat-isfactory method of reconstruction of such extensive defects is the use of free vascular flaps. In this case, we describe the results of reconstruct-ing a commissure defect extending to adjoining parts of both lips and inner buccal mucosa using extended supe-riorly based nasolabial flap and sub-mental flap.Case reportA 49-year-old male patient presented in June 2011, with a large ulcerat-ing painful mass involving the right lip commisure and right half of the upper lip and right one-third of the lower lip extending inwards involv-ing the underlying part of the inner

*Corresponding authorEmail: [email protected]

Oncology Center, Mansoura University, Daqahlia, Egypt

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For citation purposes: Elzahaby IA, Mohammed OH, Hafez MT, Abd Elaziz SR, Mosbah MM, Refky BA, et al. Reconstruction of the lip commissure with upper and lower lip full-thickness defects using submental and nasolabial flaps: a case report. Annals of Oral & Maxillofacial Surgery 2013 Oct 13;1(3):27.

ulcerating painful mass involving the right lip commisure and right half of the upper lip and right one-third of the lower lip and extending inwards involving the underlying part of the inner buccal mucosa, preoperative wedge biopsy revealed an invasive grade II squamous cell carcinoma (Figure 1a and 1b).

There were clinically significant and radiologically (by ultrasound and computed tomography) suspi-cious right upper and middle cervical lymph nodes (LNs).

The lesion was surgically removed followed by a supraomohyoid neck dissection. The surgical planning and resection of the lesion was car-ried out with widely healthy margins (proved by intraoperative frozen section examination) and with the removal of soft tissues in full- thickness. The right lip commisure, right half of the upper lip, part of skin in the cheek along with underlying

part of cheek musculature and inner buccal mucosa and right one-third of the lower lip were excised (Figure 2).

This was followed by the neck dissection (level I–IV) with extreme care to preserve the facial artery and its submental branch (the supplying vessel of the submental island flap) especially when dissecting level I cer-vical LNs (submental and submandib-ular LNs and submandibular gland). Dissection of the submandibular gland was done by safely ligating the submandibular branches of the facial artery to the gland preserving the whole facial artery along its course on the posterior aspect of the gland.

Reconstruction of the result-ant large full-thickness defect was done using two pedicled flaps, namely the nasolabial and submen-tal island flaps. A long superiorly based nasolabial flap was harvested extending down till the right lower mandibular margin (Figure 3)

with the facial artery identified and with subsequent identification of the facial artery perforator that supplies the flap (Figure 4). The nasolabial flap was rotated medi-ally for reconstruction of the upper lip and then folded upon itself to form the inner and outer aspects of the upper lip.

The submental island flap was harvested (Figure 5), based on the submental branch of the ipsi-lateral side and after completion of the neck dissection, starting from the contralateral side in the subplatysmal plane, incorporat-ing the ipsilateral anterior belly of the diagastric, as the submental artery courses beneath it in 70% of cases11. The submental flap is then rotated upwards towards the remaining defect in the lower lip and cheek and its distal part was folded inwards to reconstruct the deficient part of the inner buccal

Figure 1a: Preoperative view show-ing the lesion.

Figure 1b: Preoperative markings of the lesion.

Figure 2: The defect after tumour resection.

Figure 3: Extended superiorly based nasolabial flap.

Figure 4: Identification of facial artery perforator.

Figure 5: Submental island flap har-vested.

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mucosa. Interestingly, that the sub-mental flap is not needed to be tunnelled with subsequent fear of compression on the pedicle and venous congestion of the flap, as the part of the lower check that is pro-posed to be undermined to create the tunnel was used to extend the length of the nasolabial flap pav-ing out the way for the submental flap to be inset in the defect directly without tunnelling (Figure 6).

The histological examination of the specimen (paraffin sections) confirmed the initial biopsy, which had revealed invasive grade II squa-mous cell carcinoma. Its dimen-sions were 6 × 4 × 4 cm. The excision margins were disease free as con-firmed by the intraoperative frozen section examination, the right sub-mandibular gland and all the right cervical LNs dissected were free from tumour tissue except one sub-mental LN.

Discussion The surgical treatment of lip can-cer varies from patient to patient, depending on the size, location and type of the lesion, the degree of cell differentiation, the pres-ence or absence of infiltrated LNs and the patient’s general health condition4.

In the case presented above, the size and nature of the lesion indi-cated its full-thickness resection with wide clear margins, which resulted in an extensive soft tissue defect. So

far, in most similar cases local flaps such as Karapandzic, Estandler, Abbe and Fan flaps or mobilisation of cer-vical flaps, have been used and are recommended to reconstruct the resulting defect, depending on its size2,4,5,12,13,14,15,16,17, these local flaps are limited by significant microsto-mia and by limited oral access and the necessity of a second stage. Other local random flaps mobilised from the neck or nearby areas of the cheek are either unreliable or of limited versatility in terms of coverage of such extensive defects involving both lips and commisure.

In the last two decades, microvas-cular free flaps such as the radial fore-arm or the anterolateral thigh flaps have became the first choice and are still currently used with great success in reconstructing extensive perioral and intraoral defects7,8,9,10. However, these reconstruction techniques have advantages and disadvantages, the main ones being increased dif-ficulty, they need trained personnel, microsurgical setup and are usually associated with an increased opera-tive time and a longer hospital stay as well as functional and aesthetic prob-lems in extensive defects.

Radiotherapy is an alternative option for the treatment of malig-nant tumours in the head and neck area, while it is claimed that radio-therapy as a single treatment can have results comparable to those of surgical treatment, in small tumours mainly but also in larger ones18,19. Definitive radiation therapy, concur-rent chemoradiation and induction therapy are alternative options for patients who are not candidates for surgery. Surgery should be consid-ered for locally advanced oral cavity cancer, including lip20.

In this study, the flaps used for reconstruction of defects are axial flaps with secure blood supply unlike any proposed local random flap and harvested from nearby areas in head and neck so provide better colour

and tissue texture match unlike any other regional or distant flap transfer.

The nasolabial flap is a cutaneous axial flap based on angular artery perforators if superiorly based or facial artery perforator if inferiorly based, the tissues that compose the nasolabial flap lies over the facial and angular artery, lateral to the nasolabial fold and extends from the mid cheek above ala down to the mandibular line11. The nasola-bial flap provides good colour and texture-matched tissue to the upper and lower lips and an excellent blood supply based on the facial arteries and a natural-appearing scar at the donor site reinforces this flap as a useful adjunct in lip reconstruc-tion. Motor function is not quite as automatic as in the neurovascular Karapandzic flap, but donor tissue is more abundant.

The submental artery flap was first described by Martinet et al. in 1993. The earliest reported use of this flap for reconstruction in oral carcinoma was by Sterneand Hall in 1996. Since it was described, the flap has been extensively used for reconstruction of small to moderate size oral cavity soft tissue defects21,22,23,24,25. However, its role in lip, lip commisure defects reconstruction has not been clearly described. In addition, controversy exists about its interference with neck dissection.

Moreover, in this study, the cura-tive oncologic resection of such tumour helped to make the harvest of the flaps used (nasolabial and sub-mental flaps) easier, that wide surgi-cal resection of the tumour primary site helped good identification and preservation of the facial artery and the angular artery perforator that supplies the superiorly based nasola-bial flap and it was possible in such a situation to harvest the nasolabial flap as pedicled perforator (propel-ler) flap if needed, also the required supraomohyoid neck dissection Figure 6: Final inset of the two flaps.

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helped good identification and pres-ervation of facial vessels and their submental branches.

In summary, the reconstruction of the extensive tissue defect in the pre-sent case with the use of combined nasolabial and submental island flap was secure, reliable and produced satisfactory aesthetic and functional results (Figures 7 and 8).

Conclusion The treatment of a large squamous cell carcinoma of the lip commisure with both lip and cheek propagation has been presented in this study. The surgical removal of the lesion was extensive due to its size and nature, and was followed by neck dissection.

In the present case, the recon-struction of the extensive tissue defectproduced satisfactory aes-thetic and functional results. We didn’t find much interference with neck dissection during harvest of the submental island flap. Moreover, it is

a single stage procedure without the need for a second stage for flap divi-sion and without causing significant narrowing of the mouth and the need for further surgical intervention for rewidening it.

ConsentWritten informed consent was obtained from the patient for publi-cation of this case report and accom-panying images. All the procedures of this work were done following the approval of the ethical committee of Mansoura University.

References1. Michael R Shohet, Maurice M Khosh. Chief Editor, Arlen D Meyers. Medscape, Drugs, Diseases & Procedures. Lip reconstruction. Copyright 199–2012 by WebMD LLC. [cited 17 July 2012].2. Ntomouchtsis A, Kechagias N, Kitikidou K, Bourlidou E, Kontos K, Tsompanidou C, et al. Squamous cell carcinoma of the lip commissure. A 10-year retrospective study (1995–2004). Hellenic Arch Oral Maxillofac Surg. 2011;1:15–25.3. de Visscher Jan, Botke G, Schakenraad J, Van der Waal I. A comparison of results after radiotherapy and surgery for stage I squamouscell carcinoma of the lower lip. Head Neck. 1999 Sep;21(6):526–30.4. Renner GJ. Reconstruction of the lip. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. Missouri, United States: Mosby Elsevier; 2007.p475–524.5. Zide MF, Dean JS. Cutaneous lip lesions and reconstruction. In: Booth PW, Schen-del SA, Hausamen J, editors. Maxillofacial surgery. London: Churchill Livingstone Elsevier; 2007.p745–68.6. Sebastian P, Thomas S, Varghese BT, Iype EM, Balagopal PG, Mathew PC. The submental island flap for reconstruction of intraoral defects in oral cancer patients. Oral Oncol. 2008 Nov;44(11):1014–8.7. Cinar C, Ogur S, Arslan H, Kilic A. Adding versatility to the recons truc-tion of intraoral lining: opened pocket method. J Craniofac Surg. 2007 Jan; 18(1):198–202.8. Valentini V, Saltarel A, Cassoni A, Battisti A, Egidi S. One-stage reconstruc-tion of a defect of the oral commissure

and of the cheek with a radial fore-arm free flap. J Craniofac Surg. 2008 Nov;19(6):1508–11.9. Yamauchi M, Yotsuyanagi T, Yokoi K, Urishidate S, Yamashita K, Higuma Y. One-stage reconstruction of a large defect of the lower lip and oral commissure. Br J Plat Surg. 2005;58(5):614–8.10. Yildirim S, Gideroğlu K, Aydogdu E, Avci G, Akan M, Akoz T. Composite anterolateral thigh-fascia lata flap: a good alternative to radial forearm- palmarislongus flap for total lower lip reconstruction. Plast Reconstruct Surg. 2006 May;117(6):2033–41.11. Michael R, Glyn J. Nahai & Mathes reconstructive surgery. Nasolabial flap, volume 1, section 5C. Italy: Quality medi-cal publishing Inc.; 2012.p232–61.12. Clossmann JJ, Pogrel MA, Schmidt BL. Reconstruction of perioral defects fol-lowing resection for oral squamous cell carcinoma. J Oral Maxillofac Surg. 2006 Mar;64(3):367–74.13. Lasaridis D, Dalabiras S, Karakassis D. Modification of the Conley incision for neck dissection. J Oral Maxillofac Surg. 1994 Oct;52(10):1046–9.14. Salgarelli AC, Sartrelli F, Cantiano A, Pagani R, Collini M. Surgical treatment of lip cancer: our experience with 106 cases. J Oral Maxillofac Surg. 2009 Apr; 67(4):840–5.15. Terziqi H, Tarpila E. Reconstruction of large defect of lower lip and commis-sure using Karapandzic flap: case report. Niger J Med. 2009 Apr–Jun;18(2): 222–3.16. Unsal Tuna EE, Oksuzler O, Ozbek C, Ozdem C. Functional and aesthetic results obtained by modified Bernard recon-struction technique after tumor excision in lower lip cancers. J Plast Reconstr Aesthet Surg. 2010 Jun;63(6):981–7.17. Yamauchi M, Yotsuyanagi T, Ezoe K, Saito T, Yokoi K, Urishidate S. Estlander flap combined with an extended upper lip flap technique for large defects of lower lip with oral commisure. J Plast Reconstr Aesthet Surg. 2009 Aug;62(8):997–1003.18. Huang D, Johnson C, Schmidt R, Sismanis A, Neifeld J, Weber J. Incom-pletely resected advanced squamous cell carcinoma of the head and neck: the effectiveness of adjuvant vs. salvage radi-otherapy. Radioth Oncol. 1992 Jun;24(2): 87–93.

Figure 7: First day postoperative.

Figure 8: Five months postoperative view.

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des

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of th

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anus

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t, as

wel

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ead

and

appr

oved

the

final

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ipt.

All a

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Asso

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19. Shah P, Carew J, Singh B. Clinical evaluation and differential diagnosis. In: Shah P, Johnson N, Batsakis J, Dunitz M, editors. Oral cancer. 2003.p185–199.20. Marvaretta M Stevenson. Head and Neck Cancer Treatment Protocols. Med-scape. 2011. http://emedicine. medscape.c o m / a r t i c l e / 2 0 0 6 2 1 6 - o v e r v i e w. [Accessed on 11 July 2012].21. Demir Z, Kurtay A, Sahin U, Velidedeoglu H, Celebioglu S. Hair- bearing submental artery island flap for reconstruction of

mustache and beard. Plast Reconstr Surg. 2003 Aug;112(2):423–9.22. Demir Z, Velidedeoglu H, Celebioglu S. Repair of pharyngocutaneous fistulas with the submental artery island flap. Plast Reconstr Surg. 2005 Jan;115(1): 38–44.23. Geden EM, Buchbinder D, Urken ML. The submental island flap for palatal reconstruction: a novel technique. J Oral Maxillofac Surg. 2004 Mar;62(2): 387–90.

24. Kim JT, Kim SK, Koshima I, Moriguchi T. An anatomic study and clinical applications of the reversed submental perforator-based island flap. Plast Reconstr Surg. 2002 Jun;109(7): 2204–10.25. Salgado CJ, Mardini S, Chen HC, Chen S. Critical oropharyngocutaneous fistulas after microsurgical head and neck recon-struction: indications for management using the “tissue-plug” technique. Plast Reconstr Surg. 2003 Sep;112(4):957–63.

reconstruction of the lip commissure with upper … of the lip commissure with upper and lower lip...

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