STAIR-STEP FLAP FOR SECONDARY LOWER LIP REVISION AFTER LIP AND CHEEK COMPOSITE DEFECTS RECONSTRUCTION

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1 ORIGINAL ARTICLE STAIR-STEP FLAP FOR SECONDARY LOWER LIP REVISION AFTER LIP AND CHEEK COMPOSITE DEFECTS RECONSTRUCTION Takashi Fujiwara, MD, Chien-Chang Chen, MD, Hsiang-Shun Shih, MD, Rico P. Nebres, MD, Seng-Feng Jeng, MD, Yur-Ren Kuo, MD, PhD Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan. Accepted 30 July 2010 Published online 29 November 2010 in Wiley Online Library (wileyonlinelibrary.com). DOI: /hed Abstract: Background. Free flap reconstruction is a common procedure for through-and-through lip and cheek complex defects after cancer ablation. However, oral incompetence with unacceptable bulky flap appearance invariably occurs and needs a secondary revisionary procedure. The purpose of this article was to present our method to improve the oral competence and cosmetic appearance by the stairstep technique of flap revision. Methods. Fourteen patients who had undergone flap folding reconstruction of the lip and cheek complex defect resulting in oral incontinence were involved in this study. Thirteen patients had been treated with an anterolateral thigh flap and 1 patient had been treated with a fibular osteocutaneous flap. This revisionary stair-step technique was combined with simultaneous liposuction of the bulky flap in all cases. Results. Adequate oral continence and good contour was achieved in 12 patients. The remaining 2 patients still had mild drooling, which was managed successfully with a second stair-step flap. Conclusion. This technique is a valuable option for revision of lower lip deformity. VC 2010 Wiley Periodicals, Inc. Head Neck 33: , 2011 Keywords: stair-step flap; lower lip deformity; oral incontinence; through-and-through lip and cheek defect; flap folding A full-thickness lip and cheek defect that involves the oral commissure presents a reconstructive challenge. Effective restoration of oral competence and appearance is of high priority. Requirements of lip reconstruction include adequate support for the lower lip, adequate lip sulcus, sufficient mouth opening, and acceptable contour restoration. 1,2 Small defects, when limited in the lip area only, can be closed primarily because the resultant lip loss and asymmetry is functionally and aesthetically minimal. Medium defects can be also reconstructed effectively with local flaps. 1,2 However, once the surgical resection includes Correspondence to: Y.-R. Kuo VC 2010 Wiley Periodicals, Inc. the cheek and lip lesion, reconstruction becomes significantly more demanding. A massive resection of the cheek and lip almost always requires a free flap to reconstruct both the outer surface and inner lining. 3 There are a variety of methods available to reconstruct the complex cheek and lip defects by free tissue transfer. These reconstruction methods include composite free flaps with fascia or tendon, 3 7 free flaps in combination with remaining lip advancement, 8 10 double free flaps, 11 functioning muscle transfers, and toe web transfers. 15,16 Although each of them has been used successfully to reconstruct such complex defects, it may be technically demanding and adds to surgical time. Reconstruction of the cheek and lip can be most simplified with a single free flap without any modifications, just folding the flap onto itself for skin cover and oral lining. However, this method usually results in oral incompetence with persistent drooling, poor speech, and gravitational changes in the flaps caused by their bulk and lack of support (Figure 1). This initial result obtained significant affects to the patient s quality of life, whereas it is generally considered difficult to improve this condition. 8,11,17 Therefore, in this study, the stair-step technique was designed as a revisionary procedure for lip and cheek deformity. The aesthetic and functional improvements were assessed. MATERIALS AND METHODS A descriptive analysis was performed on 14 patients who underwent the stair-step technique for secondary lower lip revision between April 2007 and October All patients were originally treated for advanced buccal cancer (stage III or IV) by resection followed by reconstruction of through-and-through lip and cheek defects using a free flap. The traditional flap folding method that reconstructs both the outer skin and inner lining without fascial or tendinous suspension was applied. All patients developed oral 1322 Stair-Step Flap for Secondary Lower Lip Revision HEAD & NECK DOI /hed September 2011

2 patient was determined to have an adequate oral competence if he/she had a static continence during resting even though not having dynamically reconstructed lips. A summary of the individual clinical features and prior treatment are shown in Table 1. FIGURE 1. Schematic drawing of typical appearance after free flap folding method. The issues with this procedure are too much bulk and protruding deformity of the flap associated with circular contracture, downward and notching deformity of the lower lip, and insufficient alveololabial sulcus, resulting in oral incontinence and unacceptable appearance. incontinence after the initial operation. The second revision surgery was performed after disease-free interval of more than 3 months or after completion of concurrent chemoradiotherapy, with a mean duration of 11.9 months (range, 4 33 months) after the initial surgery. The patients were assessed for initial surgical defect, flap type, oral competence, and complications. The oral sphincter was defined as a complete circumference (200%) formed by the upper lip (100%) and the lower lip (100%), as previously reported. 6 A Surgical Technique. Figure 2 shows a schematic drawing of the reconstructive method. An ideal borderline of the lower vermilion is drawn (black dotted line) and the vermilion tip is identified (Figure 2A). A desirable point of the vermilion tip is determined on the ideal vermilion border (X). A line from X to the flap edge is drawn along the ideal vermilion borderline (XY), and a horizontal line (AB) is created by a distance equal to XY. The flap YAB corresponds to the first step. The second step is then created with the same height and width as the first step. The length of a side of each step is usually about 1.5 cm in our series. Incisions of the first and second step are made and extended into the alveololabial sulcus (red dotted line). The entire lower lip flap is then raised over the periosteum. At this point, the flap debulking procedure with traditional tumescent liposuction is performed. Flap thinning effectively improves the contour and produces excessive tissue that can be trimmed as demanded. Mobility of the lower lip flap is assessed again, and the final line of XY is determined and incised. The small triangular area adjacent to the sulcus (UVW) is trimmed, which allows more mobility of the rectangular flap XYUV for reconstruction of adequate sulcus. The entire lower lip flap is then rotated into place, with each step serving to close its superior neighbor. Primary closure of the donor site is achieved in a fashion similar to a bilobed flap. The end of the suture line may often end up with a dog-ear formation that requires excision of a small amount of the excess tissue. Two to 3 steps are Table 1. Individual clinical features. Case Sex/Age BMI Upper, % Lip defect Lower, % Cheek defect Outer, cm Inner, cm Flap type Flap size, cm Preoperative oral incontinence Postoperative oral incontinence Additional procedure 1 M/ ALT 13 7 Yes 2 M/ ALT 12 6 Yes 3 M/ ALT 12 5 Yes 4 M/ ALT 16 6 Yes 5 M/ FIB 20 8 Yes 6 M/ ALT Yes 7 M/ ALT 15 6 Yes 8 M/ ALT Yes 9 M/ ALT Yes Mild drooling Second stair-step 10 M/ ALT 20 7 Yes Mild drooling Second stair-step 11 M/ ALT 20 8 Yes 12 M/ ALT 15 6 Yes 13 M/ ALT 10 6 Yes 14 M/ ALT 25 8 Yes Revision of microstomia Abbreviations: BMI, body mass index; ALT, anterolateral thigh flap; FIB, fibular osteocutaneous flap incorporating the soleus muscle. Stair-Step Flap for Secondary Lower Lip Revision HEAD & NECK DOI /hed September

3 FIGURE 2. Schematic drawing of the operative method. (A) Design of stair-step flap. Each reference point is determined as follows: (A ¼ A 0 ) the tip of the lower lip vermilion, (X) an original or ideal position of the lower lip tip along the ideal lower lip vermilion border line (black dotted line), (Y ¼ Y 0 ) the ideal vermilion border line crosses the flap edge, and (B ¼ B 0 ) AB is equal in length to XY. The first step deserves the flap YAB. The height and width of the second step are the same with the first step. Incision of the first and second step is carried out and extended into the alveololabial sulcus (red dotted line). (B) The entire lower lip flap is elevated over the periosteum followed by liposuction of the transferred flap. Line XY is assessed again by advancing and rotating of the entire lower lip flap and finally incised. Triangle UVW is trimmed and then a rectangular flap XYUV is created. (C) The flap XYUV is transposed along the gingiva to reconstruct the alveololabial sulcus. (D) The entire lower lip flap is then rotated into place. Adequate alveololabial sulcus is also obtained. (E) Final result. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] usually used, but additional steps can be added to facilitate mobility or reduce tension. RESULTS There were 14 male patients; the mean age was 52.0 years (range, years); and the mean body mass index was 22.8 (range, ) in this series. The average upper and lower lip defects were 15.0% (range, 5% to 25%) and 38.2% (range, 25% to 90%), respectively. The average size of the outer cheek defects were 48.5 cm (range, cm), and of the inner lining was 37.2 cm (range, cm). Thirteen patients had undergone reconstruction with an anterolateral thigh (ALT) fasciocutaneous flap 1324 Stair-Step Flap for Secondary Lower Lip Revision HEAD & NECK DOI /hed September 2011

4 FIGURE 3. Case 1. A 56-year-old man had undergone resection of a T2N1 squamous cell carcinoma of the right buccal mucosa and reconstruction with an anterolateral thigh fasciocutaneous free flap. (A) The initial through-and-through lip and cheek defect. The total lip defect was 35%. (B) Preoperative view demonstrating oral incompetence and bulky flap. (C) Design of the stair-step flap. Rectangular flap colored in yellow (arrow) was used for reconstruction of sulcus. (D) After completion of the operation. (E, F) Twenty-six month postoperative result showing adequate oral competence, good contour, and adequacy of the mouth opening. [Color figure can be viewed in the online issue, which is available at wileyonlinelibary.com.] and 1 patient with a fibula osteocutaneous flap incorporating the soleus muscle in the initial surgery. The flap size ranged from 10 6cmto26 10 cm. In our series of 14 patients, they all developed oral incontinence after the initial operation, 12 patients achieved adequate oral competence with satisfactory aesthetic results after our revisionary procedure, whereas 2 patients (cases 9 and 10), whose original lower lip defects were 90% and 70%, still had mild drooling requiring another stair-step flap procedure. One patient developed microstomia because of overcorrection of the lower lip (case 14). This patient had a 50% defect of the lower lip and finally required an enlargement of the mouth opening with a free radial forearm flap. The mean follow-up was 16.7 months (range, 3 29 months). Table 1 summarizes the functional outcomes and follow-up status for each patient. Case Presentations. Case 1. A 56-year-old man had previously undergone excision of a T2N1 squamous cell carcinoma of the right buccal mucosa that resulted in a through-and-through lip and cheek defect. The resulting defect measured 5 5 cm externally and 6 6 cm internally, involving 10% of the upper lip and 25% of the lower lip (Figure 3A). A 13 7 cm ALT fasciocutaneous flap was raised and folded onto itself to reconstruct both the skin and buccal mucosa. The postoperative course was uneventful; however, the patient developed severe oral incontinence and bulky flap appearance (Figure 3B). Four months later, repositioning of the lower lip and defatting of the flap using our procedure was carried out (Figures 3C and 3D). Adequate oral competence and acceptable appearance was achieved 26 months postoperatively (Figures 3E and 3F). Case 14. A 48-year-old man with a T4N1 squamous cell carcinoma of the left buccal mucosa had previously undergone composite lip and cheek resection. The resulting defect measured 10 7 cm externally and 9 7 cm internally, involving 20% of the upper lip and 50% of the lower lip (Figure 4A). A 25 8 cm ALT fasciocutaneous flap was used to reconstruct both sides of the defect by folding the flap, resulting in intolerable oral incontinence (Figure 4B). Ten months after the initial surgery, the patient underwent a stair-step flap combined with liposuction for secondary revision (Figures 4B and 4C). The patient had an acceptable appearance without apparent incompetence 4 months after the revisionary procedure. However, the patient developed microstomia (Figure 4D) requiring further revision using a free radial forearm flap for an enlargement of the mouth opening. DISCUSSION A massive resection of the lip and cheek including the oral commissure presents the reconstructive surgeon with major challenges. Reconstruction techniques must restore the missing outer skin cover, inner lining, commissure definition, adequate stomal diameter, and competent oral sphincter. 3,8,10,11 A conventional flap folding method is the simplest reconstructive option, whereas noted problems of this technique include unacceptable oral incontinence and bulky flap appearance. Revisionary procedures are usually needed, but it is not an easy task to improve the functional and aesthetic results. 8,11,17 In such instances, we have successfully applied the stair-step technique combined with liposuction. Aesthetic and functional improvements were achieved. In our series, 3 patients (cases 1, 2, and 3) with smaller lip defect (less than 40%) received ALT flap folding without simultaneous reconstruction of lip competence using the remaining lip switch 8 or local flap 9,10 technique. These patients did not undergo lip competence reconstruction initially because they had severe submucous fibrosis preoperatively which resulted from betel nut Stair-Step Flap for Secondary Lower Lip Revision HEAD & NECK DOI /hed September

5 FIGURE 4. Case 14. A 48-year-old man with a T4N1 squamous cell carcinoma of the left buccal mucosa had undergone extensive lip and cheek resection and reconstruction with an anterolateral thigh fasciocutaneous free flap. (A) The extensive lip and cheek composite defects after cancer ablation. The total lip defect was 70%. (B) Preoperative appearance and design of the stair-step flap. The flap colored in yellow (arrow) was used for sulcus reconstruction. (C) Immediate postoperative appearance. A small Z-plasty of the upper lip was also performed in this case. (D) The result at 4 months with satisfactory contour but microstomia. [Color figure can be viewed in the online issue, which is available at wileyonlinelibary.com.] chewing. In such cases, the local flap procedure can easily cause oral contracture resulting in trismus. The benefits of our technique are numerous. The stair-step flap involves running Z-plasties or steps design and can be characterized as a multilobed transposition flap or rotation and advancement flap The interlocking nature of the flap decreases the tension and prevents linear scar contracture. An ideal original lip position can be achieved using this technique. In our series, this method was combined with the debulking procedure because most patients had undergone reconstruction with an ALT flap resulting in a bulky appearance. One-stage flap thinning is an alternative method to reduce the bulk but has a risk of damages to the perforator and is timeconsuming, especially when microdissection is performed. Desirable thinning of the flap can be accomplished with secondary liposuction. The debulking procedure provides flap redundancy that can be trimmed as needed or used as a flap for reconstruction of the sulcus when necessary. The depth of the alveololabial sulcus is not always sufficiently preserved in the initial surgery. The sulcus is successfully reconstructed with our method. The principal limitation of our technique is the insufficient correction of the lower lip in some situations that results with larger lip defects. In the patients presented here, there were 2 cases of oral incontinence after our procedure (cases 9 and 10) that required another stair-step flap procedure. This may be related to the original lower lip defects in the initial surgery. Original lower lip defects were 90% and 70%, respectively. Such large defects may not be reconstructed successfully with our procedure. Lower lip defects greater than 50% seem to require supplemental fascial suspension for lip support or should be considered as another reconstructive option in the primary operation. In contrast, overcorrection of the lower lip, in an attempt to completely correct the severe deformity, should also be avoided. Overcorrection in patients who had large original lower lip defects easily leads to microstomia and needs an additional revision (case 14). In our series of 14 patients, there were a total of 3 patients with undercorrection or overcorrection, in whom all the initial lower lip 1326 Stair-Step Flap for Secondary Lower Lip Revision HEAD & NECK DOI /hed September 2011

6 defects were greater than 50%. Lower lip defects less than 50% can be reconstructed successfully with our method. We designed this procedure for secondary revision after flap folding reconstruction of lip and cheek defects. Although oral incontinence can be improved, this technique is not dynamic but static reconstruction for oral competency. A true dynamic reconstruction can be achieved with functioning muscle transfer In conclusion, we have found the stair-step technique to have the ability to improve oral incontinence and ugly appearance in patients who had undergone reconstruction with free flap folding procedures. Adequate oral competence, enough alveololabial sulcus, and acceptable contour can be obtained. This approach is a valuable tool for secondary lower lip revision after composite lip and cheek reconstruction. REFERENCES 1. Tobin GR, O Daniel TG. Lip reconstruction with motor and sensory innervated composite flaps. Clin Plast Surg 1990;17: Luce EA. Reconstruction of the lower lip. Clin Plast Surg 1995;22: Kuo YR, Jeng SF, Wei FC, Su CY, Chien CY. Functional reconstruction of complex lip and cheek defect with free composite anterolateral thigh flap and vascularized fascia. Head Neck 2008;30: Furuta S, Sakaguchi Y, Iwasawa M, Kurita H, Minemura T. Reconstruction of the lips, oral commissure, and full-thickness cheek with a composite radial forearm palmaris longus free flap. Ann Plast Surg 1994;33: Katou F, Shirai N, Kamakura S, Ohki H, Motegi K. Fullthickness reconstruction of cheek defect involving oral commissure with forearm tendinocutaneous flap. Br J Oral Maxillofac Surg 1996;34: Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Total lower lip reconstruction with a composite radial forearm-palmaris longus tendon flap: a clinical series. Plast Reconstr Surg 2004;113: Yildirim S, Gideroğlu K, Aydogdu E, Avci G, Akan M, Aköz T. Composite anterolateral thigh-fascia lata flap: a good alternative to radial forearm-palmaris longus flap for total lower lip reconstruction. Plast Reconstr Surg 2006;117: Cordeiro PG, Santamaria E. Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps. Plast Reconstr Surg 1999;103: Yokoo S, Tahara S, Tsuji Y, et al. Functional and aesthetic reconstruction of full-thickness cheek, oral commissure and vermilion. J Craniomaxillofac Surg 2001;29: Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Reconstruction of concomitant lip and cheek through-and-through defects with combined free flap and an advancement flap from the remaining lip. Plast Reconstr Surg 2004;113: Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Reconstruction of extensive composite mandibular defects with large lip involvement by using double free flaps and fascia lata grafts for oral sphincters. Plast Reconstr Surg 2005;115: Ueda K, Oba S, Ohtani K, Amano N, Fumiyama Y. Functional lower lip reconstruction with a forearm flap combined with a free gracilis muscle transfer. J Plast Reconstr Aesthet Surg 2006;59: Ninkovic M, Spanio di Spilimbergo S, Ninkovic M. Lower lip reconstruction: introduction of a new procedure using a functioning gracilis muscle free flap. Plast Reconstr Surg 2007;119: Ueda K, Oba S, Nakai K, Okada M, Kurokawa N, Nuri T. Functional reconstruction of the upper and lower lips and commissure with a forearm flap combined with a free gracilis muscle transfer. J Plast Reconstr Aesthet Surg 2009;62:e Naasan A, Quaba AA. Reconstruction of the oral commissure by vascularised toe web transfer. Br J Plast Surg 1990;43: Koshima I, Inagawa K, Urushibara K, Moriguchi T. Combined submental flap with toe web for reconstruction of the lip with oral commissure. Br J Plast Surg 2000;53: Huang WC, Chen HC, Jain V, et al. Reconstruction of through-and-through cheek defects involving the oral commissure, using chimeric flaps from the thigh lateral femoral circumflex system. Plast Reconstr Surg 2002;109: ; discussion Dreyer TM. The stair-step flap for nasal alar reconstruction. Plast Reconstr Surg 1984;74: Hallock GG, Dreyer TM. The stair-step flap for nasal reconstruction. Ann Plast Surg 1987;18: Leach BC, Cook J. Revisionary technique for alar rim notching: the stair-step flap. Dermatol Surg 2009;35: Stair-Step Flap for Secondary Lower Lip Revision HEAD & NECK DOI /hed September