Functional Reconstruction of Lower Lip with Free Split Rectus Abdominis Muscle Flap

Purpose

The lips are very important aesthetic and functional unit of the face during  articulation, mastication, smile, kissing and oral competence.¹ Reconstruction of the lips should ensure both function and aesthetic apperances without any disturbing of the face.^1,2 In this study, we present functional reconstruction of the lower lip with free split rectus abdominis muscle flap.

 

Material and Methods

Between 2014 and 2016 years, 3 patients were operated for squamous cell carcinoma (SCC) of lower lip. Before surgery, patient’s medical records were reviewed for age, sex, previous treatment, size and localization of affected area, neck metastasis. Initial surgical resection was performed with wide surgical margine. After resection, the patients had 50%,75%,100% defects of the lower lip, respectively. A vertical incision was made on the linea semilunaris of the abdomen, sheath of the rectus muscle was explored. The third page of the rectus muscle was disected from upper and lower tendinous intersections. Course of the intercostal nerve of the dissected third page was identified  from the T7 to T12 thoracic intercostal nerve  with electromyograph(EMG). The medial part of the dissected muscle page was elevated with this intercostal nerve and medial perforators of the deep inferior epigastric vessels.³ Flap was folded in length and inserted to the lower lip defect. Anastomoses were completed to the ipsilateral facial artery, epigastric vein and marginal mandibular branch of the facial nerve. The muscle flap was completely covered with skin graft. Donor side was closed primary. Lower lips were evaluated with physical examination including oral competans and drolling, sensory examination with Semmes Weinstein Monoflament tests and functional examination with EMG. Patients were followed for 18 month, 25 month and 38 month respectively.

 

Result

Two patients were male, other was female. Ages of them were 64, 79 and 83 years old. There was no complication after free flap surgery. While all flaps were bulky at the first 3 month, dimensions of flaps reduced to 12th months. Color differantion with surrounding tissues, drooling and articulation problem was improved three month after surgery. Motor innervation and sensation of the reconstructed part was acceptable after 12^th month after surgery. There was no abdominal hernia and bulging, limitation of trunk flexion and extansion in all patients. All patients were satisfied with final appearance. The donor area scar was ignored by patients.

 

Conclusion

Various flap options have been reported for aesthetic and functional reconstsuction of large full thickness defects of lower lip.^1,2 The free partial medial rectus muscle flap is also an alternative flap for fullthickness large defects of lower lip with good aesthetic and functional results, preserving function of the abdominal muscle.

References

1- Jallali N, Malata CM. Reconstruction of concomitant total loss of the upper and lower lips with a free vertical rectus abdominis flap. Microsurgery. 2005;25(2):118-20.

2- Ninkovic M, Spanio di Spilimbergo S, Kim Evans KF, Ninkovic M. Lower lip reconstruction using a functioning gracilis muscle free flap. Semin Plast Surg. 2010 May;24(2):212-8.

 

3-Buntic RF, Brooks D. Free partial medial rectus muscle flap for closure of complex extremity wounds. Plast Reconstr Surg. 2005 Oct;116(5):1434-7.