Lower Lip Reconstruction Using a Functioning Gracilis Muscle Free Flap

ABSTRACT

The lips are highly visible structures on the face, providing oral competence and expressing emotion. The reconstruction of large full-thickness defects of the lips is a formidable challenge for the plastic surgeon. The most challenging defect of the lower lip is full thickness, larger than two thirds. Such an extensive defect requires either staged reconstruction or a flap of distant tissue. We consider that the gracilis muscle, due to its anatomic and functional features, is the ideal flap for reconstruction of the lips. A functioning gracilis matches all the requisites and allows normal movements that are uniform to all of the lip. The new commissure is symmetric and moves simultaneously with the residual commissure due to innervation by the facial nerve. Our indications to use the functioning gracilis muscle flap in lip reconstruction are as follows: resection of the lower lip larger than one quarter of the lip length in a patient younger than 60 years; resection larger than one third of the lip in all patients. When performing a free gracilis flap for lip reconstruction, we consider that, if possible, a facial artery musculomucosal flap and sensitive neurotization should be included to restore sensation of the reconstructed lip.

KEYWORDS

Facial artery musculomucosal flap - gracilis muscle free flap - lower lip

REFERENCES

• 1 Mathes S, Nahai F Reconstructive Surgery: Principles, Anatomy and Technique. Vol. 1. New York, NY; Churchill Livingstone 1997: 1173-1191
• 2 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 1472-1480
• 3 Burt J D, Burns A J, Muzaffar A R et al.. Total soft-tissue reconstruction of the middle and lower face with multiple simultaneous free flaps in a pediatric patient.  Plast Reconstr Surg. 2000;  105 2440-2447
• 4 Luce E A. Reconstruction of the lower lip.  Clin Plast Surg. 1995;  22 109-121
• 5 Jackson J T. Lip reconstruction. In: Jackson JT Local Flaps in Head and Neck Reconstruction. St. Louis, MO; Mosby 1985: 327-411
• 6 Galyon S W, Frodel J L. Lip and perioral defects.  Otolaryngol Clin North Am. 2001;  34 647-664
• 7 Bernard C. Cancer de la levre inferieure operè par un procede nouveau.  Bull Mem Soc Chir Paris. 1853;  3 357-364
• 8 von Burow C A. Beschreibung einer neuen transplantations Method (Method der seitlichen Dreiecke) zum Wiederersatz verlorengegangener Teile des Gesichts. Berlin, Germany; Nauk 1855
• 9 Webster R C, Coffey R J, Kelleher R E. Total and partial reconstruction of the lower lip with innervated muscle-bearing flaps.  Plast Reconstr Surg. 1960;  25 360-371
• 10 Karapandzic M. Reconstruction of lip defects by local arterial flaps.  Br J Plast Surg. 1974;  27 93-97
• 11 McGregor I A. Reconstruction of the lower lip.  Br J Plast Surg. 1983;  36 40-47
• 12 Nakajima T, Yoshimura Y, Kami T. Reconstruction of the lower lip with a fan-shaped flap based on the facial artery.  Br J Plast Surg. 1984;  37 52-54
• 13 Fujimori R. “Gate flap” for the total reconstruction of the lower lip.  Br J Plast Surg. 1980;  33 340-345
• 14 Baker S. Reconstruction of the lip. In: Baker SR, Swanson NA Local Flaps in Facial Reconstruction. St. Louis, MO; Mosby 1995: 389-396
• 15 Converse J M. Technique for the repair of defects of the lips and cheeks. In: Converse JM Reconstructive Plastic Surgery. Vol. 3. Philadelphia, PA; WB Saunders 1977: 1544-1558
• 16 Bakamjian V Y, Long M, Rigg B. Experience with the medially based deltopectoral flap in reconstructuve surgery of the head and neck.  Br J Plast Surg. 1971;  24 174-183
• 17 Kroll S S. Reconstructive facial surgery. In: Evans GR Operative Plastic Surgery. New York, NY; McGraw-Hill 2000: 289-307
• 18 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;  53 616-619
• 19 Wei F C, Tan B K, Chen I H, Hau S P, Liau C T. Mimicking lip features in free-flap reconstruction of lip defects.  Br J Plast Surg. 2001;  54 8-11
• 20 Sakai S, Soeda S, Endo T, Ishii M, Uchiumi E. A compound radial artery forearm flap for the reconstruction of lip and chin defect.  Br J Plast Surg. 1989;  42 337-338
• 21 Kroll S S. Staged sequential flap reconstruction for lower lip defects.  Plast Reconstr Surg. 1991;  88 620-625 discussion 626-627
• 22 Williams III E F, Setzen G, Mulvaney M J. Modified Bernard-Burow cheek advancement and cross-lip flap for total lip reconstruction.  Arch Otolaryngol Head Neck Surg. 1996;  122 1253-1258
• 23 Gillies H D, Millard D R. The Principles and Art of Plastic Surgery. Boston, MA; Little, Brown 1957
• 24 Jabaley M E, Orcutt T W, Clement R L. Applications of the Karapandzic principle of lip reconstruction after excision of lip cancer.  Am J Surg. 1976;  132 529-532
• 25 Yoshida T, Sugihara T, Ohura T, Minakawa H, Igawa H. Double cross lip flaps for reconstruction of the lower lip.  J Dermatol. 1993;  20 351-357
• 26 Rudkin G H, Carlsen B T, Miller T A. Nasolabial flap reconstruction of large defects of the lower lip.  Plast Reconstr Surg. 2003;  111 810-817
• 27 Gürel M, Alic B, Seyhan A, Cilengir M. Total lower lip reconstruction in advanced squamous carcinoma: application of the gate-flap technique.  Ann Plast Surg. 1992;  28 434-441
• 28 Sadove R C, Luce E A, McGrath P C. Reconstruction of the lower lip and chin with the composite radial forearm-palmaris longus free flap.  Plast Reconstr Surg. 1991;  88 209-214
• 29 Carroll C M, Pathak I, Irish J, Neligan P C, Gullane P J. Reconstruction of total lower lip and chin defects using the composite radial forearm–palmaris longus tendon free flap.  Arch Facial Plast Surg. 2000;  2 53-56
• 30 Shinohara H, Iwasawa M, Kitazawa T, Kushima H. Functional lip reconstruction with a radial forearm free flap combined with a masseter muscle transfer after wide total excision of the chin.  Ann Plast Surg. 2000;  45 71-73
• 31 Pribaz J, Stephens W, Crespo L, Gifford G. A new intraoral flap: facial artery musculomucosal (FAMM) flap.  Plast Reconstr Surg. 1992;  90 421-429
• 32 Vriens J P, Acosta R, Soutar D S, Webster M H. Recovery of sensation in the radial forearm free flap in oral reconstruction.  Plast Reconstr Surg. 1996;  98 649-656
• 33 Vesper M, Heiland M, Blake F, Flinzberg S, Schmelzle R. Clinical and histological results of sensory recovery after radial flap transfer.  Clin Oral Investig. 2002;  6 114-118