British Journal of Plastic Surgery (2005) 58, 258 262 CASE REPORTS Combined tongue flap and V Y advancement flap for lower lip defects Kenji Yano*, Ko Hosokawa, Tateki Kubo Department of Plastic and Reconstructive Surgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita-shi, Osaka 565-0871, Japan Received 10 March 2004; accepted 21 October 2004 KEYWORDS V Y advancement flap; Tongue flap; Lower lip defects; Squamous cell carcinoma Summary A combined tongue flap and V Y advanced flap were used for reconstruction of the lower lip after radical excision of squamous cell carcinoma. This V Y advancement flap is useful because the procedure does not require any difficult technique, and preservation of the orbicularis oris muscle and the branch of the mental artery and nerve are possible. The vermilion is reconstructed with a tongue flap, with almost no disturbance in the patients speaking or eating and satisfactory cosmetic results. We describe this procedure in two cases. Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. Squamous cell carcinoma (SCC) occurs frequently on the lower lip and surgical excision is the main treatment. The lower lip area is difficult to reconstruct, and is very complex morphologically and anatomically. Cosmesis requires reconstruction of the infravermilion defect by facial skin of normal texture and colour, in addition to reconstruction of the vermilion border. Various reconstructive approaches for defects of the lower lip have been described, but few address the wide transverse shallow defects. In two cases with wide transverse shallow defects of the lower lip after resection of SCC, a V Y advancement flap was used to replace the skin of the lower lip, and a tongue flap was used to * Corresponding author. Tel.: C81 6 6879 6056; fax: C81 6 6879 6059. E-mail address: knjyano@psurg.med.osaka-u.ac.jp (K. Yano). replace the mucosal surface and vermilion. The aim of this study was to assess the efficacy of V Y advancement flap and tongue flap for transverse narrow defects of the lower lip. Operative technique The tumor is resected with a 1 cm margin in an approximately rectangular shape (Fig. 1). The mental V Y advancement flap is designed in the shape of a triangle with its apex inferiorly, at the edge of the mandible. Only the skin and subcutaneous tissue are incised, thus preserving the orbicularis oris muscle, depressor labii inferioris muscle, and mentalis muscle. For upward advancement of the flap it is necessary to dissect the orbicularis oris muscle plane at least 1 or 2 cm lateral to the flap and to dissect subcutaneously the S0007-1226/$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2004.10.021
Combined tongue flap and V Y advancement flap for lower lip defects 259 Figure 1 (a) Preoperative design, (b) loss of substance and design of a triangular muscle cutaneous flap, (c) V Y flap is advanced, (d) distal undersurface tongue flap is sutured, (e) postoperative view. apex of the flap. The flap is advanced upward to the lip defect as an orbicularis oris musculocutaneous flap preserving the oral sphincter. The skin and subcutaneous tissue are sutured in two layers in a Y fashion, joining the remaining vermilion border and the upper end of the flap. Next, mucosal coverage is provided by the tongue flap. A rectangular tongue flap is designed on the inferior surface to fit the vermilion defect. The tongue flap is elevated and inset to vermilion defect. The tongue flap is cut off after 2 weeks and the oral side of the vermilion is sutured. The donor site of the tongue is closed primarily. Case reports Case 1 A 55-year-old woman was admitted with a biopsyproven 2.5!1.0 cm 2 well differentiated SCC situated on the lower lip. For treatment of the tumor, the lower lip from the white lip to the vermilion with normal tissue margins of 5 10 mm was excised. The height of the white lip defect was about 1 cm (Fig. 2(A)). Reconstruction of the white lip defects was performed with a 3.5!4.0 cm 2 triangular musculocutaneous flap. The flap was advanced upward as a subcutaneous pedicle flap and was fixed by joining the remaining vermilion border and the upper end of the flap together (Fig. 2(B)). The vermilion was reconstructed by a tongue flap, which measured 3.5!1.0 cm 2 (Fig. 2(C)). Two weeks later, the tongue flap was divided and the donor site sutured. The follow-up period was 4 years with no recurrence. The lip function was excellent, and dentures were used without any problems (Fig. 2(D)). Case 2 An 81-year-old man was admitted with a 2.5! 1.2 cm 2 well differentiated SCC with submucous induration situated on the lower lip. No lymph nodes were palpable. Under general anesthesia, wide excision of the tumor was performed with normal tissue margins of 1 cm (Fig. 3(A)). The white lip of the lower lip defect was reconstructed with a 4!4.5 cm 2 triangular musculocutaneous flap. A 4! 1cm 2 tongue flap was used to provide mucosal cover (Fig. 3(B)). The tongue flap was divided and the donor site of the tongue sutured after 2 weeks. He had a good aesthetic result and good aesthetic muscle function. He used dentures without any problems during a follow-up period of 15 months (Fig. 3(C)). Discussion Various flap procedures for reconstruction of lower
260 K. Yano et al. Figure 2 (A) Squamous cell carcinoma marked to be resected and a triangular flap was designed, (B) V Y flap was advanced to the defect and distal undersurface tongue flap was designed, (C) the tongue flap in place, ((D) and (E)) the results at 3 years and 3 months after surgery with the lips at rest and with the mouth open. lip defects have been described. Successful reconstruction of the lower lip requires certain criteria. The reconstructed lip should be sensate, retain the sphincter or muscle function, oppose its vermilion to the vermilion of the upper lip to make a watertight continent seal, and allow sufficient opening for food and dentures. In addition, it is important to achieve an acceptable aesthetic appearance, that is, complete skin cover and oral lining, and a semblance of the vermilion border. V -shaped or W -shaped defects of up to onethird of the lower lip can be closed primarily without undue tension or distortion of the anatomy with an acceptable reduction of the oral stoma. However, when a defect involving one-third of the lower lip is created, reconstruction can be planned by the use of local flaps or free tissue transfer. Lip switch techniques are recommended for defects ranging between one-third and one-half of the lower lip size. For defects larger than one-half of the lower lip, the technique of advancement of the cheek tissue by the Webster-Bernard approach is widely used, but the tension of the closure has frequently resulted in a tight lip that function poorly. A more satisfactory procedure for defects of this magnitude is the Karapandzic rotation flap,
Combined tongue flap and V Y advancement flap for lower lip defects 261 Figure 3 (A) Squamous cell carcinoma marked to be resected, (B) V Y flap was advanced to the defect and distal undersurface tongue flap was sutured, ((C) and (D)) the results at 1 year and 3 months after surgery with the lips at rest and with the mouth open. although microsomia is inevitable. 1 Other applications for reconstruction of large full-thickness defects of the lower lip include double cross lip flaps, rotation flaps with various modifications, and free flaps. Some local flaps retain motor innervation, 1,2 but frequently, the transposed tissue is denervated and therefore does not exhibit adequate sensation or immediate normal function of the oral aperture, both of which are desirable. For transverse narrow defects of the lower lip, the platysma musculocutaneous flap with a triangular skin island and the mental neurovascular V Y advancement island flap from both sides of the chin were reported. 3,4 Our reconstructive procedure is simple upward advancement of tissues from the chin as musculocutaneous flap, thus covering the lip defect and preserving the muscles for sphincteric function. With the advancement of V Y flaps, a lip curtain of adequate dimensions is achieved. The lip height of our patients was within normal limits, and good vestibular access was achieved and proved suitable for use of dentures. This mental V Y advancement flap is suitable for the transverse narrow defects in the lower lip. Reconstruction of the vermilion border can be achieved with tattooing, 5 uni- or bi-pedicled mucosal flaps, 6,7 musculomucosal flap, 8 lip-sharing, 9 simple grafting, 10 or tongue flaps. 11,12 Our reconstructive alternative for the vermilion is the use of a flap raised from the ventral surface of the tongue. This procedure has given us very good aesthetic results. This combination serves to preserve the full transverse width of the oral commissure. Its disadvantage is that it is necessary to maintain the tongue attached to the lip for a period of 2 weeks, and then the pedicle is divided in a second surgical stage. The patient must tolerate an open mouth and bite-blocks. This vermilion reconstruction does not provide immediate sensory innervation, but recovery of the sensory innervation, at least to a protective level, can be expected. The patients are provided with a generous and functional oral aperture that allows oral hygiene, denture placement, and oral feedings without any anatomical constriction. The orbicularis oris muscle remains sufficient, and the functional and aesthetic requirements of a dynamic lower lip can be met by this relatively simple procedure without any significant donor site morbidity. Our results indicate that the combined tongue flap and V Y advanced flap is
262 safe and can be used to reconstruct transverse narrow defects in the lower lip with good functional and aesthetic results. References 1. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93 7. 2. Fujimori R. Gate flap for the total reconstruction of the lower lip. Br J Plast Surg 1980;33:340 5. 3. Moschella F, Cordova A. Platysma muscle cutaneous flap for large defects of the lower lip and mental region. Plast Reconstr Surg 1998;101:1803 9. 4. Bayramicli M, Numanoglu A, Tezel E. The mental V Y advancement flap in functional lower lip reconstruction. Plast Reconstr Surg 1997;100:1682 90. K. Yano et al. 5. Furuta S, Hataya Y, Watanabe T, Yuzuriha S. Vermilionplasty using medical tattooing after radical forarm flap. Br J Plast Surg 1994;47:422 4. 6. Lustig J, Librus H, Neder A. Bipedicled myomucosal flap for reconstruction of the lip after vermilionectomy. Oral Surg Oral Med Oral Pathol 1994;77:594 7. 7. Wagner JD, Newman MH. Bipedicled axial cross-lip flap for correction of major vermilion deficiency after cleft lip repair. Cleft Palate Craniofac J 1994;31:148 51. 8. Landes CA, Kovacs AF. Nine-year experience with extended use of the commissure-based buccal musculomucosal flap. Plast Reconstr Surg 2003;111:1029 39. 9. Standoli L. Cross lip flap in vermilion reconstruction. Ann Plast Surg 1994;32:214 7. 10. Ahuja RB. Vermilion reconstruction with labia minora graft. Plast Reconstr Surg 1993;92:1418 9. 11. Bakamjian V. Use of tongue flaps in lower-lip reconstruction. Br J Plast Surg 1964;17:76 87. 12. Mcgregor IA. The tongue flap in lip surgery. Br J Plast Surg 1966;19:253 63.