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Introduction

The lips have essential and diverse functions, including oral competence, deglutition, articulation, and expression of emotion. The lips are brought together to close the mouth by the role of the orbicularis oris, a complex sphincter muscle [1]. Some of the muscle fibers of the orbicularis oris derive from intrinsic fibers of the lips, whereas others derive from other facial muscles that insert into the lips [2-3]. The platysma, depressor labii inferioris, and depressor anguli oris muscles mainly control depression and retraction of the lower lip. The primary motor nerves of the lips are the facial nerve's buccal and marginal mandibular rami. The marginal mandibular supplies the lower lip depressors. Sensory innervation of the lips is via the infraorbital and mental branches of the trigeminal nerve [2-4] and supplies from superior and inferior labial arteries, with venous drainage to the anterior facial vein [2-4] lymphatic drainage is through submental and submandibular lymph nodes [2-4]. Researchers have described many reconstructive techniques to overcome significant defects, such as "cross-flap" developed by Abbé and Estlander [5-6], using the opposite lip with the various modifications suggested [7-8], and Karapandzic technique [9]. This technique provides the excellent advantage of preserving the nerves and blood vessels of the flaps and allows an excellent sphincteric function to be maintained [10-11]. Bernard- Burow's method and other versions (fan-flap procedure) are also helpful in cases with more lip loss [12]. Also, new flaps have been introduced, each of which has advantages and disadvantages [13-17].

Lip reconstruction aims to maintain oral competence, mobility, and sensation and obtain the best aesthetic results. When the size of the stoma becomes less than 50% after reconstruction, it can be problematic for those who wear dentures. Maintaining harmony, symmetry, and adequate size is critical for cosmesis [18]. After excision, it is necessary to repair the sphincter ring using all four layers (mucosa, muscle, subcutaneous tissue, and skin) simultaneously [19]. Reconstruction should provide an adequate oral opening and mucosa adjacent to the commissure to avoid contracture [20-21]. The present study aimed to investigate a new technique for lower lip reconstruction after tumor excision resulting in a medium-sized defect.

Methods

This study is a surgical technique report from a single center. The original technique was based on our experience with about 100 patients in 25 years. A total of 10 patients referred to our hospital from 2105 to 2018 participated in this study and were followed up for three years. Informed consent was obtained from patients before participation in the study. Lower lip defects occurred in all patients following squamous cell carcinoma excision. The patients were in stage 3 of TNM classification, and none of them had positive lymph nodes. No antibiotics were given before surgery.

Surgical technique

Wide local excision of the lower lip tumors was performed under general anesthesia. Reconstruction was undertaken after the margins were shown to be free of cancer by frozen sections. In this technique, the lower lip defect will primarily be repaired even if the defect is more than 30% of the lip. After excising the tumor, A bilateral 10mm to 15mm horizontal skin incision begins from the commissures to the lateral sides (Figure 1A). Then the skin and mucosa will be dissected from the underlying orbicularis muscle, and the muscle will be cut partially about 15 mm on each side (Figure 1B). Commonly no vessels needed to be ligated and back cut. Two sides of the lip (tumor site defect) will be advanced and sutured in four layers separately, and a vertical suture line will be created (Figure 1C). Finally, the median of the dissected mucosa in the commissures will be sutured to the angle of incised skin. Then complete mucosa to skin suturing (Figure 1C).

Results

The technique used in this study has a history of 25 years of experience and has almost not any complications in these few years. Since our data during those 25 years is incomplete, we have conducted the study on ten patients. The patients included two females and eight males with a mean age of 61. The defect size was all above 50% except in one case. Five patients had hypertension, and 5 had diabetes mellitus (Table 1). The average operation time was about 70 minutes. Sutures were drawn between 5 and 7 days. Early and late postoperative results were satisfactory. No second surgery for modification was needed. At a 3-year follow-up, the patients were doing well with excellent functional and aesthetic outcomes, and there was no recurrence. Lip apertures and movements were normal, with sufficient mouth opening and oral competence and good volume and quality of the vermillion. The patients have no complaints of drooling. Speech and sensation were preserved, and highly pleased with the outcome. Figure 2 shows a case in pre-surgical and post-surgical (Figure 2).

Discussion

There are many surgical techniques for the reconstruction of the lower lip. The results of the traditional methods have been adequate and sometimes excellent, especially in elderly patients with thin lips. However, the patients, especially young patients, have suboptimal aesthetic problems. For defects less than 30%, a primary repair is an acceptable option, and it's not challenging. For defects of more than 30% of the lower lip, which is the most challenging among surgeons, several flaps are proposed: the Abbe flap [20], the neurovascular Karapandzic flap [9], and the Bernard-Webster flap [22]. For more significant defects, not including the angles of the mouth, Gillies's fan is a good choice [23]. One of the choices for Defects involving the commissure is the Estlander flap [5]. All of them have advantages and disadvantages. In the case of local flaps, flap loss, blunting of the repaired commissure, lip asymmetry, sensory loss, hypersensitivity, edema, microstomia, poor oral competence with drooling, undesirable scarring, and flap necrosis must be considered. The Karapandzic flap has the potential risk of microstomia and blunting of the oral commissure [24]. With the Karapandzic flap, we have to maintain lip mobility with preserved sensation and competence, but reconstruction of significant defects inevitably results in microstomia, necessitating secondary commissuroplasty [25]. The Webster-Bernard procedure using cheek advancement flaps can give an appropriate lip reconstruction but involves a sizeable perioral tissue loss. Also, it has significant perioral scarring with contour deformity [26]. In addition, effacement of gingivo-buccal sulcus and notching of the central lip has been described as common aesthetic disadvantages [27].

In the Estlander flap, rotation of a lateral area of the upper lip to the commissure is done first, and a second surgery is necessary to reconstruct the commissure angle. Therefore, it needs two operations. The Gillies fan flap has enough tissue to repair with no tension, but the commissure is distorted and blunted, and the lower lip gets short [28]. Also, it has a long suture line, distorting the cosmesis. Analysis for aesthetic results was based on those with pre-and postoperative photographs. Oral competence was measured by muscular integrity and aperture. The orbicularis muscle was partially cut and correctly functioned, and the muscular integrity was preserved. . The aperture and mobility were patient-reporting and asked by dentures and eating problem when eating by spoons or big morsels No drooling was reported, and the severity of drooling was measured by the Blasco index [29]. Fortunately, none of the above problems were reported by patients. And overall the oral competence was good.

Among various techniques for lower lip reconstruction,this technique seems safe and straightforward. Still, other surgeons need to use this method to measure all aspects of it and express their opinions.

Authors'contributions

This work was carried out in collaboration between all authors, and all authors read and approved the final manuscript.

Conflict of interest

Authors have declared that no conflict of interest exists.