Nasolabial flap for oral cavity reconstruction - Vula - University of ...

OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &NECK OPERATIVE SURGERYNASOLABIAL FLAP FOR ORAL CAVITY RECONSTRUCTIONHarry Wright, Scott Stephan, James NettervilleDesigned as a true myocutaneous flappedicled on the facial artery, the nasolabialflap is a robust and versatile flap that iswell suited to single-stage reconstructionof oral cavity defects or to staged reconstructionsof facial defects (Figure 1). Thischapter will focus on oral cavity reconstruction.The redundant skin extendingfrom the medial canthus of the eye to theinferior margin of the mandible (nasolabialsulcus and nasofacial groove) defines thedonor site for the nasolabial flap. This areais relatively hairless except for the lowercheek in males, an important considerationin oral cavity reconstruction. The flap itselfis comprised of skin, subcutaneous tissueand the underlying musculature.artery and provides the blood supply to thenasolabial muscle and skin. This allows forhigh viability and permits bold thinningand shaping. The facial artery has fourmain branches in the face: the inferiorlabial artery, superior labial artery, alarartery and lateral nasal artery, andterminates as the angular artery. In amajority of dissections, the facial arterytakes a medial course as shown in Figures1 & 2, rather than a lateral course as shownin Figure 3 (unpublished data). The arteryresides in the dense fibrous tissue at theoral commissure and continues along thesuperior border of the upper lip to the nasalala. It then continues in a medial coursealong the nasofacial groove toward themedial canthus of the eye. Arterial perforatorsare especially concentrated in theinferior two-thirds of the nasolabialgroove.Figure 1: Relationship of the facial arteryto the design of the nasolabial flapSurgical AnatomyBlood SupplyThe subdermal plexus is supplied by feedervessels from the branches of the facialFigure 2: The facial artery displayed in acadaver dissection, showing the morecommon medial course

Figure 12: Wound closure and final resultFigure 14: Outline of flapCase #2: Mouth floor reconstructionThis floor of mouth cancer resectionresulted in an alveolar ridge, gingiva, andfloor of mouth defect; the inferior borderof the defect is at the level of the superiorborder of the mandible (Figure 13). Thedefect was reconstructed with a nasolabialflap (Figures 14-16).Though the flap is hairless in the imageshown, the surgeon must anticipate theimplications of transferring hair‐bearingskin intraorally.Figure 15: Facial artery is bluntly dissecttedFigure 16: Flap inset into floor of mouthFigure 13: Defect following resection5

Case #3: Mouth floor reconstructionFigures 17-20 illustrate the postoperativeresults of reconstruction of an anteriorfloor of mouth defect crossing the midline.Figure 20: Though the right upper lip isparalysed, the concomitant lip lift providedby the harvest of nasolabial donor skinaids with symmetry at restFigure 17: The robust nasolabial flapminimises the risk of ankyloglossia.Case #4: Buccal cavity reconstructionThe robust blood supply to the nasolabialflap permits shaping of the flap toprecisely fill the defect (Figures 21-24).Figure 18: Early postoperative imageshows aesthetically acceptable appearanceof donor siteFigure 21: Buccal defectFigure 19: Later image shows a wellhealedfloor of mouth reconstruction6

Figure 21: Flap inset into buccal defectFigure 22: Final cosmetic resultCase #5: Palate reconstruction(postoperative)Figure 23 demonstrates a healed palatalreconstruction, with an implant visible fora dental prosthesis.Figure 21: Healed flap in buccal defectFigure 23: Healed palatal defect7

Reconstruction of palatal defects requiresthat the inferior border of the incision beapproximately at the level of the oralcommissure. Note the excellent camouflagingof the scar and the facial symmetryat rest (Figure 24). When smiling thepatient demonstrates the expected paralysisof the ipsilateral upper lip which isgenerally well-tolerated (Figure 25); thisadverse outcome is further discussedbelow.Case 6: Bilateral nasolabial flapsThis patient has a large defect of the hardpalate, alveolus and gingivobuccal sulcus(Figure 26). Bilateral nasolabial flaps wereraised (Figure 27). In Figure 28 the terminalbranch of the facial artery i.e. the angularartery, is demonstrated.Figure 26: Defect of hard palate, alveolusand gingivobuccal sulcusFigure 24: Excellent camouflage of scarand facial symmetry at restFigure 25: Asymmetry with smilingFigure 27: Bilateral nasolabial flaps8

Figure 31: Healed facial scarsAdverse OutcomesFigure 28: Angular artery visibleUpper lip weaknessUpper lip weakness may result if theterminal buccal branches of the facialnerve supplying lip elevators are lysed or ifthe principle lip elevators (zygomaticusmajor/minor, levator labii alique nasi,levator anguli oris) are completelydivided. Muscle disruption may occurwhen extensive mobilisation and rotationof the flap is required.Figure 29: Flap being inset in a side-bysideconfigurationPostoperative images show well-healeddonor sites and intact and symmetricelevation of the corners of the mouth i.e.intact cranial nerve VII (Figures 30. 31).Figure 30: Healed palatal reconstructionA unilateral nasolabial flap typically doesnot result in any appreciable ipsilateral lipweakness. As a correlation, deinnervatedAbbe flap reconstruction of the upper liphas been shown on electromyography (1and 5 years postop) to regain 80 and 100%reinnervation of the transposed musclesegment. 1 However, extensive disruptionof innervation and mimetic muscleintegrity during harvesting of bilateralnasolabial flaps may result in clinicallyappreciable weakness of the upper lip.Though permanent, it is usually welltolerated. As shown in the selected casesabove, the resulting upper lip weakness ismitigated by the mild lip lift provided byclosure of the donor site.9

Oral competenceBilateral upper lip weakness and numbnesscould significantly impair oral competence,especially lip-pursing, and must beconsidered if bilateral nasolabial flaps areplanned. Special care should be taken toavoid disruption of the distal facial nervebranches in such cases.SummaryNasolabial flap reconstruction of intraoraldefects is a well-recognised technique.Because the flap is pedicled on the facialartery, single-stage closure with a smallerpedicle may be achieved if the proximalportion of the flap is de-epithelialised. Arobust blood supply helps to ensure flapviability and prevents flap breakdown andfistula formation even in adverse conditionsof excess tension or mild compressionof the transbuccal pedicle. The bulkprovided by the facial musculature helps tofill larger defects. It does not impair speechand causes only minimal donor sitemorbidity. The flap is not overly timeconsumingor technically difficult tomaster; however knowledge of the relevantanatomy is essential.ReferencesBurget G, Menick F. Aesthetic restorationof one-half of the upper lip. Plast ReconstrSurg. 1986;78(5):583–93AcknowledgementsIllustrations by Paul GrossCadaver dissections by David Haynes,MD FACSAuthorsHarry V. Wright MD, MSFellowFacial Plastic and Reconstructive SurgeryOtolaryngology and Head & Neck SurgeryUniversity of South FloridaUSAdr.hvwright@gmail.comScott Stephan MDAssistant ProfessorFacial and Plastic SurgeryVanderbilt Bill Wilkerson CenterNashville, TEUSAstephan@vanderbilt.eduJames L. Netterville MDDirector of Head and Neck SurgeryVanderbilt Bill Wilkerson CenterNashville, TEUSAjames.netterville@vanderbilt.eduEditorJohan Fagan MBChB, FCORL, MMedProfessor and ChairmanDivision of OtolaryngologyUniversity of Cape TownCape Town, South Africajohannes.fagan@uct.ac.zaTHE OPEN ACCESS ATLAS OFOTOLARYNGOLOGY, HEAD &NECK OPERATIVE SURGERYwww.entdev.uct.ac.zaThe Open Access Atlas of Otolaryngology, Head &Neck Operative Surgery by Johan Fagan (Editor)johannes.fagan@uct.ac.za is licensed under a CreativeCommons Attribution - Non-Commercial 3.0 UnportedLicense10