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Research Article Open Access

Volume 1 • Issue 2 • 1000104OtolaryngolISSN:2161-119X Otolaryngology an open access journal

Open AccessResearch Article

Szymczyk et al. Otolaryngol 2011, 1:2 DOI: 10.4172/2161-119X.1000104

IntroductionPostresection defect of the total lip, especially when it is associated

with regional tissues i.e. cheek skin, floor of the mouth, mandible, presents a real challenge for reconstructive surgeon. For total lip recreation many different techniques can be considered. Microvascular free tissue transfer is the latest major advance in lower lip reconstructions and the main contributing factor in the quality of life improvement. The modern techniques are able to deliver well-vascularised tissues to allow closure of even most complex and extended postresection defects. The aim of lip restoration is to provide proper oral lining and external cheek skin and to reconstruct oral competence. There are several issues in lower lip reconstruction using microvascular tissues that must be considered, including defect’s size, aesthetic units, support, recreation of the vermillion and defects of associated tissues. Among many certain donor sites the radial forearm free flap (RFFF) has become a golden standard for majority of patients with total lip postresection defects, especially in cases where the use of local techniques may result in functional and/or aesthetic loss [1].

RFFF provides thin, pliable fasciocutaneous tissue for intra- and extra oral defects. This particular free flap is highly reliable because of large diameter of its artery and veins. The vascular pedicle is ideal with long vessels capable to reach the opposite side of the neck if necessary [5]. That characteristic makes it a useful one for lower face postresection defects reconstruction.

Aim of the StudyThe aim of this paper is to present the group of 10 consecutive

patients with lower lip cancer, who underwent the RFFF reconstruction to develop a precise, based on anatomical details, plan of incorporating

*Corresponding author: Łukasz Krakowczyk, Department of Oncological Surgery, Cancer Centre, M.C Sklodowska Memorial Institute, Wybrzeże Armii Krajowej 15, Gliwice, Poland, E-mail: [email protected]

Received June 06, 2011; Accepted November 03, 2011; Published November 07, 2011

Citation: Szymczyk C, Maciejewski A, Wierzgoń J, Krakowczyk Ł, Grajek M, et al. (2011) The Use of Radial Forearm Free Flap for Total Lower Lip Reconstruction: The Analysis of 10 Consequentive Cases and Quality of Life Evaluation. Otolaryngol 1:104. doi:10.4172/2161-119X.1000104

Copyright: © 2011 Szymczyk C, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

The Use of Radial Forearm Free Flap for Total Lower Lip Reconstruction: The Analysis of 10 Consequentive Cases and Quality of Life Evaluation Cezary Szymczyk, Adam Maciejewski, Janusz Wierzgoń, Łukasz Krakowczyk*, Maciej Grajek, Piotr Jędrzejewski, Mirosław Dobrut, Ryszard Szumniak, Rafał Ulczok and Stanisław Półtorak

Department of Oncological Surgery, Cancer Centre, M.C Sklodowska Memorial Institute, Wybrzeże Armii Krajowej 15, Gliwice, Poland

radial forearm free flap in lower lip reconstruction. Qualities of life, mainly aesthetic and functional results are also analyzed.

Material and MethodsMaterial: From March 2002 to December 2005, 10 consecutive

patients with squamous cell cancer of the lower lip, underwent complex surgical treatment in the Dept. of Surgical Oncology in Cancer Center MSC Memorial Institute, Gliwice, Poland. The only eligible criterion was the use of radial forearm free flaps for lower lip reconstruction. All reconstructive procedures were performed at the time of resection. None of the patients underwent second corrections.

There were 8 men and 2 women, and M:F ratio was 4:1. The average age was 56 years. In whole group cancer was in advanced stage (T 3/4).

Methods: All patients underwent surgical resection of primary tumor en block with regional neck nodes. Type of lymph nodes

AbstractBackground: Postresective defect of the total lip, especially when associated with soft tissues of lower face still

remains a challenge for adequate reconstruction. Among many options microvascular free tissue transfer is the latest major advance and the main contributing factor in the quality of life improvement. The modern techniques are able to deliver well-vascularised tissues which allow to reconstruct even most complex and extended defects. The aim of lip restoration is to provide proper oral lining and external cheek skin and to reconstruct oral competence. There are several issues in lower lip reconstruction using microvascular tissues that must be considered, including defect’s size, aesthetic units, support, recreation of the vermillion and defects of associated tissues. Among many certain donor sites the radial forearm free flap (RFFF) has become a golden standard for majority of patients with total lip postressective defects.

Materials and Methods: The aim of this paper is to present the group of 10 consecutive patients with lower lip cancer, where RFFF was used for functional lower lip reconstruction, with analysis of life quality. In the material the patient characteristics is presented with the details of RFFF modifications according to the type of lip suspension. Based on own QOL questionnaire, the functional and aesthetic results were analysed.

Results: The results suggest that the careful and detailed planning of the size, shape and type of lip suspension influence both functional and aesthetic results. Static lip suspension for defects limited to lower lip only is comparable to dynamic suspension in cases where the defect is complex and extended. Results of quality of life analysis may be a predictive factor influencing the choice of individual flap modification including the type of lip suspension

Conclusions: Our experience with free radial forearm free flap for total lip reconstruction suggests that the careful and detailed planning of the size, shape and type of lip suspension influence both functional and aesthetic results.

Oto

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dissection was adequate to the stage of disease. In all cases wide local resection were performed. Technique of the reconstruction was chosen individually, based on type and localization of postresection defect, general patient’s condition and his expectations as well. In all cases radial fasciocutaneous forearm free flap was chosen. Volume and location of soft tissue loss directly forced the size and shape of skin paddle. The size of skin island corresponded with the contour of the postresection defect. In all cases a template duplicated the defect was made. The extraoral defects varied from 18 to 45 cm2 and the intaoral were between 15 and 30 cm2. In 3 cases the marginal mandibulectomy was performed. In 7 cases the flap was harvested with the palmaris longus tendon crossing the internal surface. In 4 cases the tendon was sutured to the deep surface of the oral commissures and in remaining 3 cases (were resection was more extended) it was attached to the zygomatic arches.

In 4 cases the RFFF was associated with antebrachal sensitive nerve which was anastomosed to menthal nerve stump. The detailed characteristic of the material is presented in Table 1.

The vascular pedicle length varied from 10 to 16 cm. In 8 cases arterial anastomoses were performed with facial artery end to end and in remaining 2 with thyroid superior. In about 70% RFFF single vein (concomitant) was connected with jugular internal or facial vain and in the remaining 30% two veins were simultaneously anastomized.

In all cases split-thickness skin grafts were used for donor site closure (taken from the thigh). In 8 cases radial forearm free flap was used alone (Figure 1a,b,2a,b) and in two cases the RFFF was combined with fibula free flap due to mandible infiltration (Figure 3a,b). In those cases osteoseptocutaeous free fibula was able to reconstruct the segment of the mandible and its skin island was used to recreate the oral vestibule and floor of the mouth.

Quality of life evaluation: There are still too little studies on the QOL of patients after microvascular reconstructions for lower lip cancer. This is the reason why we recently introduce the routine practice to own questionnaire of functional and aesthetic outcome after combined surgery (resection + reconstruction) for all patients

PATIENT AGE TNMDEFECT SIZE (cm) ANASTOMOSES

LIP SUSPENSION REINNERVATIONEXTRAORAL INTRAORAL ARTERIAL VENOUS

1 58 T4N1 8X4 6X4 RADIAL - FACIAL CONCOM. – JUG. INTPALMARIS LONG. TEND. – ORAL COM -

2 45 T3N0 6X3 5X3 RADIAL - FACIAL CONCOM - FACIAL - -

3 67 T4NO 9X5 7X4 + MARG. MADIBULECTOMYRADIAL – THYROID SUP. DOUBLE

PALMARIS LONG. TEND. – ZYG. ARCH

ANTEBR. – MENTHAL

4 61 T4N2 10X4 11X5 + MARG. MADIBULECTOMY RADIAL - FACIALCONNECTION – JUG. INT.

PALMARIS LONG. TEND. – ZYG. ARCH

ANTEBR. – MENTHAL

5 42 TTN1 7X3 7X3 RADIAL - FACIAL CONNECTION – JUG. INT.PALMARIS LONG. TEND. – ORAL COM -

6 57 T3N1 5X5 5X3 RADIAL - FACIAL CONCOM. – JUG. INT - -

7 53 T4N0 8X4 6X5 RADIAL – THYROID SUP.CONNECTION – JUG. INT

PALMARIS LONG. TEND. – ORAL COM -

8 69 T4N1 9X5 10X3 + MARG. MADIBULECTOMY RADIAL - FACIAL DOUBLEPALMARIS LONG. TEND. – ZYG. ARCH

ANTEBR. – MENTHAL

9 65 T3N2 6X3 6X3 RADIAL - FACIAL CONCOM - FACIAL - -

10 46 T4N0 8X6 7X4 RADIAL - FACIAL CONNECTION - FACIALPALMARIS LONG. TEND. - ORAL COM

ANTEBR. – MENTHAL

Table 1: Characteristic of the clinical material.

Table 2: QOL questionairre and results.

PATIENT DEFECT SIZE (cm2)QUALITY OF LIFE – AESTHETIC RESULT QUALITY OF LIFE – FUNCTIONAL RESULTSymmetry Vermillon shape Lip size & contour Scars status Lip mobility Oral closure Articulation Presence of microstomia

1 56 1 0 1 1 0 1 1 12 33 1 1 1 0 1 1 1 13 73 0 0 1 1 1 1 1 14 95 0 1 0 1 0 0 1 15 42 1 1 1 1 1 1 0 16 40 1 1 1 1 1 1 1 17 62 1 0 0 0 0 1 1 18 75 1 0 0 1 0 1 1 19 36 1 1 1 1 1 1 1 110 70 0 0 0 1 0 1 1 1

Table 3: Aesthetic and functional results according to defect size and type of lip suspension.

DEFECT SIZE LIP SUSPENSION

30 – 60(5 patients)>60(5 patients)

PALM. LONG. TENDON – ORAL COMMISURE (4 patients)

PALM. LONG. TENDON – ZYGOMATIC ARCH (3 patients)

NO SUSPENSION(3 patients)

AESTHETIC EFFECT 3,6 2 2,3 2,3 3,7FUNCTIONAL EFFECT 3,6 3 3 3 4

BOTH 7 5 5,3 5,3 7,7


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reconstruction outcome, that means aesthetic and functional results have been quantified using own Quality Of Life Questionnaires. The questionnaire takes into account the impact of surgical procedures on the QOL in relation to a radial forearm free flap for lower lip reconstruction. Eight-item scale includes measures of symmetry, vermillon shape, size and contour of the recreated lip, the status of postoperative scars and functional results such as: lip mobility, oral closure, articulation and presence of the microstomia. Each parameter was considered as good (1) or bad (0). Every patient answered once to this questionnaire, i.e. 6 months after surgery (Table 2).

The patients are interviewed by the QOL Office (sociologists and physiologists) independently of the treatment team. The present analysis includes small number of cases which can be considered only as a preliminary report.

ResultsIn the whole group of 10 patients tumor resection was radical

and surgical margins were histopathologically negative. Actuarial 12-months recurrence-free survival is 100%.

10 flaps were successfully transferred (100%). Two flaps were explored within 24 hours after surgery, because of vein thrombosis and two was salvaged. One patient developed postoperative fistula in submandibular region which required surgical retreatment with

(a)

(b)

Figure 1: a,b – Pre- and postoperative view of patient – the use of RFFF with tendon lip suspension.

(a)

(b)

Figure 2: a,b – The steps of total lip reconstruction with RFFF.

successful outcome. In one case (after flap salvage surgery) partial flap loss (smaller than 30%) occurred. There were no donor site complications except two cases were skin graft partial loss was noted (requiring second regrafting).

According to quality of life assessment the material was subdivided into two groups, based on postressective defect volume (Gr. A- 30-60 cm2, Gr. B- > 60 cm2). Both aesthetic and functional outcome were better in Group A than in Group B (70 vs 50 points). Quality of life analysis did not show any differences between different modalities of lip suspension (palmaris longus tendon – zygomatic arch vs palmaris longus tendon – orbicularis oris muscle). Moreover better results were noticed in patients were no lip suspension was performed.

Complete oral competence was achieved in all but one patient (the largest defect with marginal mandibulectomy). The type of lip suspension except one case did not affect the speech and articulation function. None of patients presented microstomia. Detailed QOL results are presented in Table 3.

Although the results of reinnervation were not analyzed, no subjective differences were noticed between 4 cases were antebrachial was anastomosed with menthal nerve and cases were no sensate recreation was performed.


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DiscussionThe lips play an important role in facial expression, speech

and eating. To achieve optimal functional and aesthetic outcome a significant attention must be put to make a right plan of both resection and reconstruction. Although for total lip defects many different methods have been suggested, the introduction of microvascular techniques allowed for single stage reconstruction of a complex and extended tissue loss. Among many techniques the radial forearm free flap is the most commonly used for soft tissue defect only. It provides a decent support especially when it is transferred with palmaris longus tendon. In different authors opinion the tendon can be sutured to either nasolabial area, the malar periostium, or to the bilateral modiolus. Those variations allow reconstruct a static suspension only. Recently, Sawhney [2] proposed the technique of dynamic suspension, where the tendon is connected to transferred masseter muscle. Jeng et al. [3] reported the principles of looping the palmaris longus tendon to orbicularis oris muscle. Our experiences show that this technique of tendon fixation is able to restore complete circumference of oral sphincter. Moreover, this variant of dynamic reconstruction is an easy, one stage procedure providing similar functional outcome comparing to cases where the tendon was sutured to zygomatic arches [4-6]. In our limited data the results show only the idea of different radial flap modalities influencing the quality of life outcome and

therefore it is presented as preliminary report. The QOL analysis presents no differences between static and dynamic lip suspension. It can be explained by careful choice of suturing the palmaris longus tendon to zygomatic arch or orbicularis oris muscle due to the size of postressective defect volume and extension. In cases were the defect was relatively small and limited to lower lip only, no suspension was performed with good functional and aesthetic results. In very thin patient the flap is sometimes to thin and does not provide bulk. This can be overcome with a brachiradialis muscle being harvested with the skin flap to add bulk. For bulky flaps secondary thinning in the appropriate zones with liposuction will improve the aesthetics and the use of fat injection is also of value secondary bulking of the neo-lip [7,8]. From aesthetic point of view the use of distant flaps i.e. radial forearm gives the color mismatch and according to forearm anatomy, bulk can decrease the aesthetic outcome. Therefore the flap thinning or second procedures are often required. In our series after harvesting and detaching the flap was individually thinned when necessary, with no second procedures. In 8 of 10 cases the proper lip symmetry was achieved, and in more than half of the patients size of the lip and its contour, with good status of scars were noticed [9,10].

In our series there were no differences in sensation whether the menthal nerve was anastomosed with antebrachial nerve or not. It can be explained by short period of observation and small group of analyzed patients and on the other hand by difficulties of comparing the sensate recreation coming from anastomosing the menthal and antebrachial nerve and spontaneous reinnervation itself [11].

ConclusionsOur experience with free radial forearm free flap for total lip

reconstruction suggests that the careful and detailed planning of the size, shape and type of lip suspension influence both functional and aesthetic results. Static lip suspension for defects limited to lower lip only is comparable to dynamic suspension in cases where the defect is complex and extended. Results of quality of life analysis may be a predictive factor influencing the choice of individual flap modification including the type of lip suspension.

References

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2. Sawhney CP (1986) Reanimation of lower lip reconstructed by flaps. Br J Plast Surg 39: 114-117.

3. Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY (2004) Total lower lip reconstruction with a composite radial forearm – palmaris longus tenton flap: a clinical series. Plast Reconstr Surg; 113: 19-23.

4. Furuta S, Sakaguchi Y, Iwasawa M, Kurita H, Minemura T (1994) Reconstruction of the lips, oral commissure, and full thickness cheek with a composite radial forearm palmaris longus free flap. Ann Plast Surg 33: 544-547.

5. Ozdemir R, Ortak T, Kocer U, Celebioğlu S, Sensöz O, et al. (2003) Total lower lip reconstruction using sensate composite radial forearm flap. J Craniofac Surg 14: 393-405.

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9. Coppit GL, Lin DT, Burkey BB (2004) Current concepts in lip reconstruction. Curr Opin Otolaryngol Head Neck Surg 12: 281-287.

(a)

(b)

Figure 3: a,b – The use of double independent free flaps – radial forearm for lip and fibula for mandible reconstruction.

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10. Zilinsky I, Winkler E, Weiss G, Haik J, Tamir J, et al. (2001) Total lower lip reconstruction with innervated muscle-bearing flaps: a modification of the Webster flap. Dermatol Surg 27: 687-691.

11. Roldan JC, Teschke M, Fritzer E, Dunsche A, Harle F, et al. (2007) Reconstruction of the lower lip: Rationale to preserve the aesthetic units of the face. Plast Reconstr Surg 120: 1231-1239.

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TitleCorresponding authorAbstractIntroductionAim of the Study Material and Methods ResultsDiscussionConclusionsTable 1Table 2Table 3Figure 1Figure 2Figure 3References

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n g o l o g y: Open r y A l a c o c t O es Otolaryngology: Open Access · 2018. 7. 5. · The modern techniques are able to deliver well-vascularised tissues to ... The extraoral