Combination of two local flaps for the reconstruction of oral commissure

INTRODUCTION

The oral commissure has an important role in oral sphincter function. The upper and lower lips meet at the corner of mouth which, in anatomy called oral commissure, normally lies in vertical line from iris. Approximately 25% of all oral cavity carcinomas involve lips and oral commissure. The management of resulting oral commissure defect remains significant reconstructive challenge, requiring meticulous preoperative planning and surgical technique to optimise the functional and cosmetic outcome.

Various flaps alone were reported to close the mucosal defects, however defects involves mucosa along with oral commissure, combination of flaps often used.

Here we are reporting a case involving large mucosal carcinoma involving oral commissure in which excisional defect was repaired using combination of Abbe- Estlander and Nasolabial flap.

CASE REPORT

A 53 year old male patient reported to our hospital complaining of non-healing ulcer in the right side of the oral cavity.Clinical examination reveals ulcerative lesion measuring 3*3 cm in the right buccal mucosa involving oral commissure (fig.1). Level I nodes are palpable. Biopsy performed which is suggestive of well differentiated squamous cell carcinoma (fig.2). The surgery planned was wide excision plus radical neck dissection (fig.3) and reconstruction with nasolabial and abbe-Estlander flap.

Routine radical neck dissection performed as shown in figure 4. Neck dissection specimen was excised. (fig 5) Wide excision of the lesion along with involved skin was performed by giving sufficient safe margin (fig.6).

A triangular incision extending from commissure of equal height and half the width of the defect is marked (fig.7) and carried down to the subcutaneous tissue planes. The medial end of the flap which was still anchored to upper lip was left behind with sufficient tissue at the vermilion border. The lateral dissection was then deepened and full thickness flap was elevated to fill the commissure defect (fig 8). Inferiorly based nasolabial flap (fig.9) raised by routine procedure with sufficient subcutaneous tissue to assure a good blood supply. The tunnel is developed by blunt dissection through deeper tissues. The flap was then inset so that skin part of the flap facing oral cavity (fig 10). Closure of all open wound was done (fig 11).

Follow-up done for 1 year, there was no flap failure; the symmetry of the oral commissure is maintained. The appearance is cosmetically and functionally satisfactory.

DISCUSSION

The main goals of reconstruction remain the restoration of oral competence, maintenance of mouth opening and restoration of normal anatomic relations.

The first evidence of lip and oral commissure reconstruction is seen as far back as 3000 B.C. in Hindu writings, as well as in the Sanskrit writings of Sushruta in 1000 B.C. Many modern techniques and methods to restore oral commissure were described by Dieffenbach, Sabatini, Abbe & Estlander in 19th century. In 1838, Sebatini first described the cross-lip flap transfer of a lower lip midline wedge to philtral defect. This technique was modified by Abbe-Estlander in 1872¹ .

There are several methods for the reconstruction of larger cheek defects. Pedicled distant flaps such as deltopectoralis, pectoralis major myocutaneous are most common. The medially based deltopectoral flap was introduced in the head and neck reconstruction during 1960's. The main disadvantage of deltopectoral flap is the need to form an oral fistula and close it during a second operation. The pectoralis major myocutaneous flap has gained more popularity than deltopectoral flap since 1980's. However, sometimes the pectoralis major myocutaneous flap is too bulky and the position of the nipple at the donor site become distorted which causes aesthetic problem. The microsurgical and free tissue transfers have been common option for reconstruction of cheek defects since 1980. The rectus abdominus musculocutaneous flap and free radial forearm flap are popular microvascular free tissue flap techniques in cheek defect reconstructions. However, rectus abdominus flap often seems too bulky and may lead to abdominal hernia. There are several complications with tissue transfer total flap loss, fistula, and dehiscence, hematoma and donor site morbidity.

Repair of cheek defects involving the oral commissure has always been a challenge for surgeons while the skin and mucosal cover is the goal but sphincteric function must be restored. Reconstruction strategies of cheek defects are dependent on the type and amount of tissue resected.

In this case, we used Abbe-Estlander flap for oral commissure reconstruction and mucosal defect was closed by nasolabial flap. The remaining cheek skin defect was achieved by local advancement of cheek-skin without any distortion. This is the main reason for not using distant flaps or free tissue transfer. The other reasons are deltopectoral, pectoralis major myocutaneous, rectus abdominus are too bulky in this case, they may require two stage operations and also there are chances of donor site morbidity.

Several other techniques like converse flap, Zesser-Platz flap were described for smaller defects, but the defect located at the junction of lip & commissure is better reconstructed by Abbe- Estlander flap² .Makoto Yamauchi et.al³ used Estlander flap combined with an extended upper lip flap technique for large defect of lower lip with oral commissure on 3 patients and he concluded that symmetry of oral commissure was maintained & the appearance was satisfactory.

Abbe-Estlander flap utilises the labial artery in a labial pedicle. Dougles. L. et al⁴ studied anatomical basis of the Abbe flap in cadaver heads & he described that the superior labial artery found within 10 mm of the free margin of the upper lip and inferior labial artery is variable in its course varying upto 15 mm from the free margin of the lower lip.

The advantage of this technique is sphincter mechanism is maintained, problem like pouting, drooling and fluid pooling avoided. Besides function this flap provides similar texture and colour to achieve good esthetic result. The sensory function of the reconstructed portion also can be preserved with this technique. The only disadvantage of this flap is microstomia.

Nasolabial flap is well-known, can be used for local reconstruction of moderate defects of oral cavity. Sizeable flaps are frequently available without significant postoperative distortion. When the flap is inferiorly based the beard area can usually avoided and when the flap is carried on subcutaneous pedicle its versatility increased⁵ .

CONCLUSION

Achieving the form and function of lost tissue is satisfactory reconstruction for any kind of defect. To achieve satisfactory reconstruction in large defects, combination of flaps is required. When the oral commissure is involved along with mucosal defects combination of Abbe-Estlander and Nasolabial flap can achieve good oral competence, symmetry with less morbidity.