New way to raise the V-Y advancement flap for reconstruction of the lower lip: Bipedicled orbicularis oris musculocutaneous flap technique

Abstract

We describe a new way to raise the V-Y advancement flap, which is useful for reconstruction of the lower lip. Various other methods have been reported in the past, but it has been necessary to choose the most suitable method for each particular case. A V-Y advancement flap from the submandibular region is one of the useful techniques to reconstruct the lower lip, and it is suitable for a wide horizontal defect. However, the conventional V-Y flap is insufficiently mobile and the reconstructed vermilion is thin because of the limitation of the pedicle. In such a case, the reconstructed lip may sag or cause an embarrassing defect. We developed a new way to raise the flap to obviate these problems. We use the V-Y advancement flap from the inferior margin of the defect in a conventional way after excision of the tumour, and use a mucosal flap to reconstruct the vermilion border. The skin side of the V-Y flap is undermined, and the orbicularis oris muscles are preserved on both sides as pedicles. The flap is then raised as a bipedicled musculocutaneous flap, which has adequate movement. After the flap has been sutured, the superior margin of the flap is de-epithelialised, and used to create the volume of the vermilion border. Functionally and cosmetically good results were achieved.     

Combined tongue flap and V-Y advancement flap for lower lip defects.

A combined tongue flap and V-Y advanced flap were used for reconstruction of the lower lip after radical excision of squamous cell carcinoma. This V-Y advancement flap is useful because the procedure does not require any difficult technique, and preservation of the orbicularis oris muscle and the branch of the mental artery and nerve are possible. The vermilion is reconstructed with a tongue flap, with almost no disturbance in the patients' speaking or eating and satisfactory cosmetic results. We describe this procedure in two cases.     

The subcutaneous pedicle flap: widening of its applications

The subcutaneous pedicle flap is useful for reconstruction of a relatively small defect, and there have been many reports on its use in the facial region. With careful manipulation and thought given to the selection of the patient, it is also applicable to the trunk and extremities. During the last 7 years, we have treated 80 patients who had subcutaneous pedicle flaps applied to various parts of the body (57 on the face, 12 on the trunk, and 11 on the extremities). Eleven representative patients are presented in this article. Based on our experience, we are now confident that the subcutaneous pedicle flap is useful to reconstruct a free border or transient area of different tissues, such as the eyebrow, eyelid, lip, and nose. In the trunk, e.g., in the buttock and the breast, it is useful to reconstruct the natural convexity. We prefer using the V-Y advancement type of subcutaneous pedicle flap rather than the transposition flap. To increase the mobility of the advancement flap, the distal portion of the flap is undermined just below the layer of the subdermal plexus. This may prevent postoperative bulkiness and facilitate the reconstruction of natural contour.     

颏神经血管蒂V-Y岛状推进瓣功能性修复下唇部分缺损

目的 探讨下唇部分缺损的功能修复方法.方法 对7例下唇癌患者做手术切除,形成的唇全厚缺损(缺损长度为下唇1/3至2/3)用颏神经血管束为蒂的颏部V-Y岛状推进瓣修复.结果 颏神经血管蒂V-Y岛状推进瓣全部成活,术后3个月至1年随访,无肿瘤复发,唇外观良好,修复的下唇肌功能和感觉正常.结论 颏神经血管蒂V-Y岛状推进瓣是下唇部分缺损功能性修复的理想方法.     

Interposition fascia lata sheet free graft and a composite V-Y advancement flap to correct functional incompetence of the oral sphincter

Large total or subtotal defects of the lower lip pose a significant challenge for the reconstructive surgeon. The functional reconstructing of the oral sphincter is critical for oral competence and prevention of drooling, improving speech, and eating as well as for esthetic aspects. The authors present a case of a large partial thickness defect of the lower lip and chin following an excision of a neglected basal cell carcinoma. The defect was reconstructed with an anterolateral thigh free flap. Subsequently, due to oral incompetence and lip ectropion, a tensioned interposition unfurled sheet of fascia lata free graft and a composite V-Y advancement flap were utilized to reconstruct the continuity of the oral ring and correct the lower lip ectropion. The procedure resulted in a satisfactory dynamic functional oral sphincter together with a pleasing esthetic result. Level of Evidence: Level V, therapeutic study     

颊肌黏膜瓣在宽大红唇及口轮匝肌缺损修复中的应用

目的探讨修复大面积的红唇及口轮匝肌缺损的手术方法。方法设计以面动脉前颊支为血管蒂的颊肌黏膜瓣,用以修复上或下唇宽大的红唇及口轮匝肌缺损。结果共治疗7例,5例患者术后无任何并发症,2例患者颊肌黏膜瓣尖端黏膜坏死,未累及肌层,术后创面通过黏膜上皮化而愈合,无其他并发症发生。术后早期即可测到温度觉、触觉,肌电图和电镜显示瓣内肌肉有运动神经支配。结论应用颊肌黏膜瓣可以修复用常规方法难以解决的宽大红唇及口轮匝肌缺损,并且可获得良好的形态、感觉和功能。     

Double V-Y advancement flap in the management of lower lip reconstruction

A new method for lower lip reconstruction is proposed. It is based on a double cutaneous and mucous V-Y advancement flap and is suggested for the surgical treatment of lip cancer confined between the skin and the vermilion with a horizontal spread. Sixteen patients were treated from 1996 to 2001 with this technique and the results were satisfactory both from the functional and the aesthetic standpoints.     

应用上唇外侧组织瓣旋转修复下唇缺损

目的:探求上唇外侧组织瓣在修复较大面积下唇缺损中的作用。方法:根据患者下唇缺损情况,设计上唇外侧组织瓣,旋转后插入缺损组织,同时在缺损吻合处,将上层外侧旋转瓣内侧粘膜肌肉向外牵拉形成部分新的红唇,然后逐层相对缝合,修复缺损。结果:自2003年1月应用此方法修复患者6例,术后随访1～2年,唇部外形好,无流涎,无口闭合不全,效果满意。     

Extending the extended V-Y flap

This case report demonstrates a modification of the so-called 'Extended V-Y Flap' used to simultaneously reconstruct a defect involving the upper lip, floor of nose and alar rim following tumour excision. We hope that this case serves as a reminder of the versatility of the V-Y flap in the nasolabial region, and its considerable capacity for augmentation.     

V-Y advancement flap for the reconstruction of partial and full thickness defects of the upper lip

We analysed the records of 25 patients who had their upper lips reconstructed after resection of a tumour. All the repairs were done with triangular cutaneous and musculocutaneous flaps with a skin island with V-Y advancement, and a subcutaneous or muscular pedicle with or without mucosa. The choice of flap was based on the width of the defect after the tumour had been resected. A subcutaneous pedicled flap was used in 14 patients; a musculocutaneous flap not including the mucosa in 5, and including the mucosa in 6. This flap can be used to repair upper lip defects of any thickness. The procedure is quite safe from a circulatory point of view and the flap has the advantage of requiring only one procedure. It is aesthetically satisfactory in most patients and maintains the good function and sensitivity of the lip.     

V-Y advancement flap for the reconstruction of partial and full thickness defects of the upper lip.

We analysed the records of 25 patients who had their upper lips reconstructed after resection of a tumour. All the repairs were done with triangular cutaneous and musculocutaneous flaps with a skin island with V-Y advancement, and a subcutaneous or muscular pedicle with or without mucosa. The choice of flap was based on the width of the defect after the tumour had been resected. A subcutaneous pedicled flap was used in 14 patients; a musculocutaneous flap not including the mucosa in 5, and including the mucosa in 6. This flap can be used to repair upper lip defects of any thickness. The procedure is quite safe from a circulatory point of view and the flap has the advantage of requiring only one procedure. It is aesthetically satisfactory in most patients and maintains the good function and sensitivity of the lip.     

‘The Crown flap’: a modification to the keystone flap types I and IIA

The Crown flap is a modification of the keystone flap first described by Felix Behan in 2003. A third V-Y advancement limb is incorporated into the design in the central region of the flap where the line of maximum tension exists. This added V-Y closure utilizes surrounding tissue laxity and has been found to aid in closure of the defect centrally whilst not compromising the flap. The Crown flap is a useful modification to the keystone flap. Level of Evidence: Level V, therapeutic study.     

皮肤红唇复合瓣法修复单侧完全性唇裂的临床分析

目的 介绍应用皮肤红唇复合瓣法修复单侧完全性唇裂的手术方法,并对其临床效果进行分析.方法 在裂侧唇缘设计一皮肤红唇三角瓣,内旋推向健侧,再造唇珠;口轮匝肌、鼻小柱和鼻翼外侧角的松解、复位固定;鼻底构建与鼻堤形成等多种方法,于2008年4～12月,对45例单侧完全性唇裂患儿进行手术修复.结果 术后随访1～6个月,45例单侧完全性唇裂患儿术后双侧唇高、鼻翼和唇红对称,鼻堤和唇珠明显,无鼻底凹陷,效果满意.结论 皮肤红唇复合瓣法修复单侧完全性唇裂,具有设计简单易行,切除组织量较少,瘢痕小,唇珠外形佳等特点.     

下唇交叉粘膜瓣修复外伤性上唇唇红缺损

目的：探讨针对外伤性上唇唇红部分缺损畸形的修复方法。方法：应用下唇交叉粘膜瓣，分两次手术修复上唇部分唇红缺损，唇红瓣面积最小为1．8cm×1．0cm，最大为3．0cm×2．0cm。结果：自2002年3月以来，应用下唇交叉粘膜瓣修复外伤性上唇唇红部分缺损患者共10例，粘膜瓣全部成活良好，术后外观满意。结论：应用下唇交叉粘膜瓣修复外伤性上唇唇红部分缺损畸形，具有较强的临床适应证。     

Modified bilateral advancement flap: the slide-in flap.

The bilateral V-Y advancement flaps are used commonly in the closure of circular skin defects. We modified the standard bilateral V-Y advancement flap technique to reduce the tension along the closure, and used it in 10 patients between 1995 and 1997. In the presence of a circular defect, bilateral V-Y advancement flaps were marked on the skin, with the height of the V flaps measuring 1.5 to 2 times the diameter of the defect. The limbs of the V were not drawn as straight lines, but were curved outward slightly, making the flap and its two extensions broader than the standard V-Y flap. The broad extensions of the V flaps encircled the defect from above and below. Skin incisions were made vertically down to the muscle fascia. Additional undermining was carried out to elevate the upper and lower extensions of the V flaps for a distance that equaled the radius of the defect. The upper and lower extensions of the V flap on one side were transposed into the defect and sutured to the concave base of the opposing flap V flap at its midpoint. These extensions were then sutured to each other. The extensions of the opposing V flap were then transposed into the defect; the upper being superior and the lower being inferior to the extensions of the first flap. The rest of the operation was completed by advancement of the V flaps and closure in a Y configuration. The efficient redistribution of available tissue by the combined use of transposition and advancement principles resulted in the repair of relatively large skin defects with reduced tension along the closure. Satisfactory results were obtained in all patients in this series without any surgical complication.     

Upper lip reconstruction using a modified perialar crescentic advancement flap

In reconstruction of the upper lip, it is important to observe the principle of aesthetic units and subunits. The cheek advancement flap can be modified in such a way as to achieve this; it can also reconstruct the Cupid's bow. Large upper lip defects, including skin and muscle, can be reconstructed using this technique.     

Eyelid reconstruction using a hard palate mucoperiosteal graft combined with a V-Y subcutaneously pedicled flap.

Full-thickness eyelid defects after tumour ablation require the reconstruction of two layers, the anterior and posterior lamellae. Eyelids were successfully reconstructed after removal of malignant tumours in four patients using a hard palate mucoperiosteal graft combined with a curved V-Y subcutaneously pedicled flap. Although there have been some reports of hard palate mucosal grafts for reconstruction of the posterior lamella, the graft is not sufficiently rigid to support the reconstructed eyelid without the aid of supporting materials such as cartilage grafts. The hard palate mucoperiosteal graft seems to be rigid enough to support the reconstructed eyelid without the use of cartilage or other supporting materials. The subcutaneously pedicled V-Y advancement flap is useful for reconstruction of the anterior lamella in partial eyelid defects. We used it with a modified curved design to allow easy advancement and to make postoperative scars inconspicuous.     

Lip Reconstruction of Comparatively Large Defect Including the Commissure Using Remaining Lip Tissue: A Modification of Reconstructed Method

We present two reconstructed cases after malignant skin tumor of comparatively large defects of lip including the commissure using remaining lip tissue alone. After resecting a tumor including wedge-shaped full-thickness lip tissue, a full thickness oblique incision is made at the site 5 mm distant from the contralateral commissure. The rhomboid-shaped lower lip flap is created, transposed to the defect, and sutured with the defect margin, including the upper lip, to reconstruct the commissure. The cross lip flap is created at the contralateral side of the lower lip, 5 mm from the commissure, and the defect is closed with the crosslip flap. Although our method is applicable only to selected cases, we believe that it is useful in terms of maintaining symmetry of the lip and function of the commissure in the reconstruction of comparatively large defects including the commissure.     

Reconstruction of the vermilion after "lip-shave"

During the year 1986, 12 "lip-shave" defects were reconstructed using orbicularis oris myomucosal flaps, in the Northern Ireland Plastic and Maxillo-Facial Service. Three of these were extended lip-shaves. The planning of a V-Y plasty for myomucusal advancement is described and some representative results are shown. We feel that the myomucosal advancement flap is a valuable technique to overcome some of the problems in reconstruction of the vermilion after lip-shave.     

A combined flap reconstruction for full-thickness defects of the medial canthal region.

The medial canthus is an aesthetically and functionally important area. Adequate consideration of the local anatomy is essential when reconstructing this area. We developed a combined flap technique with a simple combination of standard flaps for the treatment of extensive defects of the nose and upper and lower eyelids, including full-thickness medial canthus defect. In our technique, a median forehead island flap is used for the nasal region, the anterior surface of the eyelid is reconstructed along aesthetic unit, and the posterior surface is reconstructed with a palatal mucoperiosteal graft. A cheek flap is then used for the reconstruction of the lower eyelid. When reconstructing a small defect of the upper eyelid, the upper eyelid is advanced, while a V-Y advancement flap within the upper eyelid is used for a large defect. To reconstruct the acute angle of the medial canthus, a 0.3 mm titanium wire was passed through the tip of the tarsal plate of the upper and lower eyelids to be reconstructed and was fixed in the perforated nasal bone on the affected side. Using this technique, the acute angle of the medial canthus is well preserved after surgery, and is located symmetrically with its counterpart on the intact side. Our technique provides good reconstructive results and should serve as a valid alternative for the reconstruction of this area.