Lower lip reconstruction with Abbe–Estlander flap modification: preserving the same side vascular pedicle

Abstract

A 74-year-old man was referred to our clinic with a nonhealing crusted lower lip ulcer. On examination, an ulcerated lower lip lesion measuring 1.5 9 1.5 cm was detected at a location 1 cm from the left oral commissure approaching the midline. There was no palpable lymphadenopathy in the neck. An incisional biopsy was carried out and the lesion was reported as squamous cell carcinoma. Supra-omohyoid bilateral neck dissections were performed and the tumor was excised. Vertical full-thickness incisions were made so as to leave a safety margin of 1 cm. The defect measuring 3.5 cm was reconstructed utilizing an ipsilateral upper lip Abbe–Estlander flap, which was prepared with 3-cm length and 1.5-cm base, preserving the superior labial artery. The left upper labial artery sank deeply into the submucosal plan of the mobilized flap (Fig. 1, 2). The upper lip defect was reconstructed by primary closure. Histological examination of the specimen confirmed no metastasis in the neck, with a negative surgical margin. No complications developed in the following 6 months with satisfactory esthetic and functional results. According to the defect location and size, various lip reconstruction methods have been described. ‘’ V ‘’ or ‘’ W ‘’ shaped excision and primary closure are sufficient for smaller than 30 % lower lip defects. In 35–70 % of lower lip defects, the Karapandzic, Abbe, Estlander, McGregor or Gillies’ fan flaps, the Nakajima or Schuchardt flaps or their modifications can be used. In cases in which there is insufficient tissue in the lower lip, cheek tissue is used in Webster, Bernard and Dieffenbach advancement flaps and their various modifications. Deltopectoral or radial forearm free flaps can be options for large defects of the lip extending to the mandible [1–5]. The Abbe–Estlander flap, which is fed by the opposite superior labial artery, is a full-thickness triangular-shaped upper lip flap that creates the oral commissure and the lateral part of the lower lip. This flap begins from the medial part of the oral commissure and is approximately 1.5 9 3 cm in size. Direct rotation to the defect is completed at one stage. In our case, the lower lip was reconstructed using the modified Abbe–Estlander flap following tumor resection. We describe a method that is different from conventional methods, which protects the ipsilateral superior labial artery. It is not necessary to sacrifice the superior labial artery, which is encountered in the incision line when creating the flap. Additional dissection to expose the artery, such as that in facial arterial dissection, is not required. Therefore, no co-morbidity of the facial muscles occurs. At first, the mucosal layer of the flap is sutured to the defect area after having released a small part of the muscle. Thereafter, the flap is sutured to the defect area while preserving the artery, which is between the mucosa and the muscular layer of the flap. Protecting the ipsilateral superior labial artery does not complicate the mobility and the processing of the flap. Our modification, which goes with an intact contralateral facial artery in terms of flap feeding, may not have superiority to the classical Abbe– Estlander flap for patients who have never undergone a surgical procedure to the neck. However, in patients who This manuscript had been presented at 33rd. National Congress of Oto-Rhino-Laryngology Head and Neck Surgery, Antalya, 26–29 October 2011.