Complete lower lip reconstruction with in-folded extended pedicled deltopectoral flap: Case report and review of the literature

Olayinka A Olawoye; Oluwabunmi M Fatungase

doi:10.4103/njps.njps_1_17

CASE REPORT

Year : 2017 | Volume : 13 | Issue : 1 | Page : 24-27

Complete lower lip reconstruction with in-folded extended pedicled deltopectoral flap: Case report and review of the literature

Olayinka A Olawoye¹, Oluwabunmi M Fatungase²
¹ Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
² Department of Anaesthesia, Obafemi Awolowo College of Health Sciences, Olabisi Onabanjo University, Sagamu, Nigeria

Date of Web Publication

16-Aug-2017

Correspondence Address:
Olayinka A Olawoye
Department of Surgery, College of Medicine, University of Ibadan, Ibadan
Nigeria

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/njps.njps_1_17

Abstract

The reconstruction of extensive lower lip defects is challenging. Various options have been described for reconstructing limited extent of full thickness defects of the lower lip; however, the reconstructive options get narrower as the defect approaches 100%. Local flaps play the prominent roles in smaller defects but regional and distant flaps become the preferred choices in total and near total defects. We present the use of an in-folded extended pedicled deltopectoral flap for the reconstruction of complete lower lip defect. A 58-year-old woman presented with complete lower lip defect following failed local flaps previously employed to reconstruct the lower lip after excision of squamous cell carcinoma at another facility. She had extensive perioral scaring with complete exposure of the lower dentition. She had scar excision and two staged lower lip reconstruction with in-folded extended deltopectoral flap with satisfactory outcome. We report the successful restoration of oral competence and satisfactory esthetic outcome with the use of a simple deltopectoral flap for complete lower lip defect.

Keywords: Complete lower lip defect, deltopectoral flap, esthetics, lower lip reconstruction

How to cite this article:
Olawoye OA, Fatungase OM. Complete lower lip reconstruction with in-folded extended pedicled deltopectoral flap: Case report and review of the literature. Nigerian J Plast Surg 2017;13:24-7

How to cite this URL:
Olawoye OA, Fatungase OM. Complete lower lip reconstruction with in-folded extended pedicled deltopectoral flap: Case report and review of the literature. Nigerian J Plast Surg [serial online] 2017 [cited 2023 Sep 24];13:24-7. Available from: https://www.njps.org/text.asp?2017/13/1/24/213027

Introduction

Lower lip reconstruction for large full thickness defects greater than 75% present a challenge in maintaining oral competence, adequate mouth opening, satisfactory esthetic outcome, and restoration of good sensation. The majority of described techniques cannot meet the requirements of functional lip, good oral competence, and prevention of microstomia.^[1] Squamous cell carcinoma is a common tumor of the lower lip that requires radical excision with resultant defects that may not be amenable to linear closure. Several reconstructive options have been described by Gillies and Millard,^[2] Webster et al.^[3], Karapandzic,^[4] and Nakajima et al.^[5] All these procedures utilize local flaps often with resultant macrosomia and oral incompetence, resulting in drooling of saliva and incomprehensible speech.^[6],[7] More recently, better functional outcome and greater satisfaction have been associated with the use of composite free flaps.^{[6],[7],[8],[9],[10],[11]}

The radial forearm flap is the most commonly employed flap in this regard. In centers with limited facilities and resources for microvascular reconstructions, other options may be considered. The index patient has had two failed reconstructions with local flaps before presenting to us. She had significant perioral scarring that limited the choice of another local flap. She subsequently had scar excision and staged reconstruction with an in-folded extended deltopectoral flap with satisfactory outcome. This paper presents a relatively simple but useful reconstructive option in challenging situations like ours.

Case History

We present the case of a 58-year-old woman who was referred to our unit with a 2-year history of complete lower lip defect. She had previously been diagnosed with squamous cell carcinoma, involving most of her lower lip 5 years before her presentation for which she had two attempts at wide excision and reconstruction with local flaps at another teaching hospital. She also had adjuvant radiotherapy following the second surgery. Her main complaints were inability to maintain an oral seal, resulting in drooling of saliva. She was also worried about the significant scarring around the previous region of repair and her appearance. She did not have any feature of a loco-regional disease or distant spread.

Examination revealed a middle-aged woman who appeared anxious and worried. She appeared otherwise healthy. She had complete loss of the lower lip with exposure of the lower dentition. There were significant scarring around the remnant of the lower lip and around her cheeks from previous surgeries. Previous surgical scars were also evident on her cheeks [Figure 1] and [Figure 2].

Figure 1: Pre-operative frontal view with complete loss of lower lip and exposed lower dentition

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Figure 2: Intra-operative marking of extended right deltopectoral flap

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Operative Technique

She had excision of the scarred remnant of the lower lip and staged reconstruction with extended pedicled deltopectoral flap under general anesthesia via a nasotracheal intubation. [Figure 3] depict the intraoperative flap marking and in-set, respectively. A length of 2.5 cm of the tip of the flap was in folded to create the sulcus. The flap donor wound was closed directly in most part except for the defect over the shoulder that was resurfaced with split skin graft.

Figure 3: In-setting of In-folded right deltopectoral flap with residual secondary defect over right shoulder

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The healing progressed satisfactorily and she had flap division and in-setting 3 weeks after the initial surgery.

Postoperatively, she was able to achieve normal lip closure with concealment of her dentition and better feeding with absence of drooling of saliva [Figure 4] and [Figure 5].

Figure 4: Two weeks post flap division

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Figure 5: Six weeks post flap division

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Discussion

Cancer of the lower lip is the most common malignancy of the oral cavity, and its primary treatment is surgical. The recommended safety margin is excision of the lesion with healthy tissue at least 1 cm away from the border of the tumor. Therefore, reconstruction becomes necessary even for small lesions.^[12],[13]

Various reconstructive options have been described for lower lip reconstruction depending on the size of the defect. The options range from direct closure for defects less than one quarter of the lip length to various types of local, regional, or distant flaps.

The choice depends on the extent of the defect in addition to the surgeon’s expertise.

The goals of lower lip reconstruction are: restoration of oral competence, maintenance of adequate oral stoma, preservation of sensation, and maintenance of speech. The other goals include provision of both skin cover and oral lining; provision of lower lip vertical height, prevention of show of teeth, and to production of an esthetically satisfying result with good semblance of vermillion.^[14] The ultimate aim is to achieve a balance between adequate mouth opening and competent mouth closure, which is vital to the patient.^[14]

Of all the various options that have been described for the reconstruction of extensive lower lip defects, local flaps remain the first choice and mainstay of reconstruction because of superior functional and esthetic outcome compared with regional and free flaps.

Several surgical techniques have been reported for the reconstruction of the lower lip but only a handful of these are applicable for extensive defects involving almost the entirety of the lower lip, each of them having its own merits and demerits. Most of these techniques restore lip continuity but compromise mouth opening or sphincter function or cause significant perioral scarring and poor esthetic outcome.^[15]

The local flaps that are used for extensive lower lip defects greater than two-thirds are mainly the Gillies fan flap, Karapandzic flap, McGregor and Nakajima flap, and the Webster–Bernard flap.^{[2],[3],[4],[5]}

Nasolabial flaps and their modifications have also been used for this purpose.^{[17],[18],[19]} The Gillies fan flap brings more tissue into the lip area, but the commissure is distorted, and the lower lip is shortened.^[20]

As expected, the index patient had previous reconstruction with local flaps following the excision of squamous cell carcinoma of her lower lip. The flaps were said to have failed with resultant scarring of the perioral region. The circumstances surrounding the failed reconstruction were not known. This precluded the use of other local flaps.

With limited expertise and infrastructure for microvascular surgery, other options aside from a free flap reconstruction had to be explored.

The deltopectoral flap was first described by Bakamjian^[21] in 1965 as an option for head and neck reconstruction. It is a pedicled axial fasciocutaneous flap based on the internal mammary artery perforator. In its standard form, the lateral extent of the flap is along the deltopectoral groove. This has a reliable axial blood supply and can be transferred with a high probability of survival. The extended deltopectoral flap extends beyond the deltopectoral grove to the skin overlying the deltoid muscle. This allows for greater length and further reach to defects beyond the lower third of the head. The thinness and pliability of the flap confers on it the added advantage of in folding of its distal end which was used to create the inferior sulcus in the patient. The authors are not aware of any previous description of the infolded extended deltopectoral flap as described in this study. The flap met the functional and esthetic needs of the patient as it provided satisfactory cover for the lower dentition as well as controlled drooling of saliva.

Conclusion

The pedicled extended in folded deltopectoral flap, though a two-stage procedure is a relatively simple technique that can be used to achieve the main goals of successful reconstruction of extensive lower lip defect and may be considered as a primary or salvage procedure when there are challenges that preclude the use of any of the other commonly utilized techniques.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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