Open Access
Issue
BioMedicine
Volume 9, Number 4, December 2019
Article Number 29
Number of page(s) 3
DOI https://doi.org/10.1051/bmdcn/2019090429
Published online 14 November 2019

© Author(s) 2019. This article is published with open access by China Medical University

Licence Creative Commons
Open Access This article is distributed under terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided original author(s) and source are credited.

1. Introduction

The lips have important functional and aesthetic roles and dynamically determine the overall impression of the overtone of facial expression. Consequently, disturbance in their dynamics may lead to an exaggerated distortion of the middle and lower face regions. Defects may result from congenital anomalies, trauma, wide local excision for neoplasm, or other inciting events [1]. However, several factors pose a challenge to lip defect reconstruction. Herein, we present a double lobe flap design that combined nasolabial and infra-nasal lobes and double transposition for closing the upper and lower lips associated with commissure defects without secondary aesthetic and functional problems.

2. Clinical study

An 81-year-old woman that had undergone previous reconstruction for the left lip defect, was admitted in our Department with an ulcerating painful lesion involving the right lip commissure and right half of the upper lip and lower lip, measuring 0.4 cm × 0.6 cm in size (Figure 1A). After excision of the lesion, the defect was repaired with an adjacent double-lobe flap compressing the infra-nasal upper lateral lip lobe (named A) and paranasal lobe (named B) like shown in Figure 1B. The wounds healed uneventfully, and a satisfactory outcome was observed 9 months postoperatively (Figure 2). The pathological diagnosis of the lesion was pseudo-epitheliomas hyperplasia.

thumbnail Fig. 1

(A). View of the ulcerating painless lesion and two incisions line; one is extended along the anger lines of the cheek and the other is paranasal. (B). According to the pre- analysis for the possibility of the defect, the right commissure and right upper lateral and lower lip defects after lesion resection would belong to the infra-nasal medial plus ipsilateral commissure lip defect. Thus, at the circular outline of the lesion, two incisions were made extending along the Langer’s lines on the cheek and perinasal area, which passed and skirted from the circular base of the ala of the nose and were limited near philtrum. Then, an adjacent double-lobe flap compressing the infra-nasal upper lateral lip lobe (named A) and para-nasal lobe (named B) was raised. After gaining adequate mobilization (Figure 1.B), the combined transposition of lobe A and lobe B closed this defect. The nasolabial lobe closed the upper lateral lip lobe with half of the commissure part of the defect through transposition, and the infra-nasal lobe covered half of the commissure and the lower lip part. For matching the extension with combined transposition and easily accommodating the double transposition of two lobes, A and B, the common pedicle base of these lobes was elongated a little upward to the commissure of the upper and lower lips. In addition, lobes A and B were incised circularly in order to get the correct anatomical shape of the new commissure. The secondary defect or the donor site was closed primarily with advanced surrounding tissues.

thumbnail Fig. 2

Nine months postoperatively.

3. Discussion

Lip reconstruction remains a challenge, and esthetics and donorsite morbidity have become critical considerations in reconstruction; this is particularly relevant in central facial reconstruction. Several aesthetic units are intricately controlled by a complex series of muscles and a dynamic equilibrium exists between the opposing lips; therefore, muscles must be properly restored with an effective reconstruction approach after occurrence of defects.

The lack of any substantial fibrous framework increases the risk of anatomic distortion through wound contraction and, hence, leads to poor functional and esthetic outcomes [2]. The quality of the skin and mucosa of the lips is difficult to match with that of distant flaps; hence, local tissues provide the best results [3]. Various classical flaps have been used worldwide for lip reconstruction, including the Gillies fan flap, Karapandzic flap, Bernard-Burow-Weber flap, Jackson Technique, Abbé-Estlander flap and nasolabial flap, which reflect the overall inadequacy to suit every patient with any given defect [47]. To date, fullthickness skin graft, vascularized free flap, and adjacent flap are used for the repair of various lip defects. The adjacent flap that has a variety of designs which respect to the matched color, texture, and thickness of the defect area has been widely recommended. Most of these flaps may be the best choice for repairing lip defects; however, they are somewhat complicated to operate and require more incisions. Moreover, Asian patients have a higher tendency for scar formation after facial surgery; therefore, these techniques should be used secondarily [8]. In addition, skin laxity; sometimes makes repairing of certain defects convenient, and flaps mostly used in elderly patients are not applicable in young patients because of the aesthetic problems [9, 10]. Upper or lower lip defects and commissure defects can be reconstructed using an inferiorly based nasolabial flap, which is an excellent source of local tissue. Therefore, a double flap design combining nasolabial and infra-nasal lobes with double transposition can be used as for reconstruction of ipsilateral upper and lower lip defects in elder women. This double flap is a cutaneous axial flap based on angular artery perforator, if based superiorly or a facial artery perforator, if based inferiorly, as in the present study [11]. Even with other myriad reconstructive options for surgeons, the present double flap design is more reliable for restoring aesthetic and functional aspects of the lip. This design may be the least morbid reconstruction method for upper and lower lips associated with commissure defects compared to other various classical flaps [47], and the mean advantage of this flap is the double transposition, double lobes with a common pedicle base in which the upper and lower lips associated with commissure defects can be concomitantly closed. The circular incision between the lobes A and B help to get a good anatomical shape of the new commissure. Thus, the flap design was aesthetically oriented and uncomplicated.

In conclusion, this study presents another alternative option for the reconstruction of lip defects, especially in Asian subjects of advanced age. The flap provides good colour and texturematched tissue to the upper and lower lips. Excellent blood supply based on the facial arteries and the natural appearing scar at the donor site reinforce this flap as a useful adjunct in the reconstruction of the lip and commissure.

Conflicts of interest statement

The authors wish to disclose no conflicts of interest.

Ethical approval

All procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from the patient.

References

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All Figures

thumbnail Fig. 1

(A). View of the ulcerating painless lesion and two incisions line; one is extended along the anger lines of the cheek and the other is paranasal. (B). According to the pre- analysis for the possibility of the defect, the right commissure and right upper lateral and lower lip defects after lesion resection would belong to the infra-nasal medial plus ipsilateral commissure lip defect. Thus, at the circular outline of the lesion, two incisions were made extending along the Langer’s lines on the cheek and perinasal area, which passed and skirted from the circular base of the ala of the nose and were limited near philtrum. Then, an adjacent double-lobe flap compressing the infra-nasal upper lateral lip lobe (named A) and para-nasal lobe (named B) was raised. After gaining adequate mobilization (Figure 1.B), the combined transposition of lobe A and lobe B closed this defect. The nasolabial lobe closed the upper lateral lip lobe with half of the commissure part of the defect through transposition, and the infra-nasal lobe covered half of the commissure and the lower lip part. For matching the extension with combined transposition and easily accommodating the double transposition of two lobes, A and B, the common pedicle base of these lobes was elongated a little upward to the commissure of the upper and lower lips. In addition, lobes A and B were incised circularly in order to get the correct anatomical shape of the new commissure. The secondary defect or the donor site was closed primarily with advanced surrounding tissues.

In the text
thumbnail Fig. 2

Nine months postoperatively.

In the text

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