Reconstruction of the Facial Mimetic Muscles with Sub-Segmental Muscles Associated with Free Perforator Flaps

Musculocutaneous losses in the lips and perilip region have been treated with local flaps or sensitive fasciocutaneous free flaps. However, these add scars on the face, increase morbidity by causing injury in nearby regions and the muscles involved, often lead to severe microstomy depending on which structures are affected, and extension of the lesions or resultant cold lip. Faciocutaneous free flaps, such as antebrachial, scapular and parascapular flaps have been utilized for treatment of large losses.

The author presented three cases of musculocutaneous latissimus dorsi free perforators flaps used for sensitive and motor functions. As a treatment for total loss of the inferior lip, two small segments of muscle were included as a neo–orbicularis and neo–depressor of the inferior lip. In the fronto–orbital–malar–paranasal area of musclocutaneous losses, three small segments of muscle were added as a neo–elevator of the superior lip, neo–zygomatic and neo–orbicularis oculi. In another case of extensive loss of the right segment of the superior lip, one segment of muscle was used as a neo–orbicularis muscle and the adjacent muscles were reattached as the central segment of the orbicular oris m.(muscle), levator of the superior lip m., zygomatic m., risorious m., and inferior angle depressor m. In these two cases, the skin included on the free perforator flaps reconstructed the inner and outer layer. The vermilion was pigmented. After exenteration had been done by an ophthalmologist, the skin covered the fronto–orbital–malar–paranasal area. The causes of the lip losses were a pit–bull dog bite (an adult woman and a 9-year–old child) and MARSA (methicilin antibiotic–resistant Staphylococcus a.) infection after sutured laceration post vehicular accident (11-year–old child).

In two cases, the buccal ramus nerve of the facial nerve and the facial vessels were chosen as recipients for anastomosis. In another case, the mandible marginal ramus of the facial nerve and the superficialis temporalis vessels were chosen as recipients for anastomosis of the thoracodorsal neurovascular pedicle.

The advantages of these flaps were preservation of the innervation, as well as of the remaining muscle, with maintenance of their functional activity at the donor site. Rich vascularization of the skin was observed after defatting of the flap for reducing bulk. Functional symmetry of the facial mimic muscles was observed, as well as preservation of a proportional balance between the right and left sides of the commissure.

The three initial cases of this series were carefully evaluated and the author presented pre-, trans-, and postoperative aspects, as well as functional and aesthetic results, showing the mimic and phonic results after phonotherapy, and considering motor, sensitive, and proprioceptive responses. Refinements were analyzed.