Sakai et al described a composite radial forearm plamaris longus flap (CRFPL) for total lower lip reconstruction. However, this technique is not fully capable of preserving satisfactory oral competence, especially when the patients are speaking or eating. Valuable modifications and refinement of the technique of using a composite radial forearm-palmaris longus flap have been described to improve the functional outcomes of this technique. The purpose of this case report is to present a successful empowered static and partial dynamic reconstruction of the massive lower lip defect with the CRFPL.A 70-year-old patient presented with a large tumor of the lower lip with two years of clinical history was referred to our institution. The patient underwent resection of the tumor with bilateral modified neck dissection. The CRFPL flap was harvested from the left forearm at the same time as the tumor resection. The flap was folded over the palmaris longus tendon. We passed the free edges of the palmaris longus tendon through the modiolus bilaterally in appropriate fashion from the subcutaneous plan superficially to the malar eminence, following the direction of the zygomaticus major muscle rather than passing them intramuscularly through the modiolus. Afterward, they were anchored to the malar eminences with suitable tension to achieve the empowered sling effect. Postoperative period was uneventful. The follow-up period was one year. There was no local recurrence or regional metastasis. The patient had excellent oral competence both in resting condition and during speaking and eating. Mouth opening was sufficient. He was able to resume a regular diet and had near-normal speech. The aesthetic result was also satisfactory. In conclusion, regardless of the which modification of the reconstruction with CRFPL flap is chosen in such cases, successful reconstruction providing the oral competence and acceptable aesthetic appearance requires the precise pre- and intraoperative planning, respectfulness to the modiolus and suitable placement and anchorage of the palmaris longus tendon into key anatomic points.

Reconstruction after total maxillectomy with preservation of the orbital contents is technically more challenging than when the maxillectomy is combined with orbital exenteration. It results in severe complications if the orbital content is not supported. We would like to introduce a new technique using free rectus abdominis myocutaneous (RAM) flap with anterior rectus sheath to support the orbital content in a patient who underwent globe-sparing total maxillectomy. The large resection of the recurrent maxillary peripheral nerve sheath tumor was performed in a 34-year-old male patient. Right free RAM flap was harvested simultaneously with the tumor resection. The anterior sheath of upper portion of the rectus muscle was also incorporated into the flap. The free edge of the upper anterior rectus sheath was anchored to three different points: Lateral rim, medial rim and the posterior remnant of the bony orbital floor with non-absorbable suture. Consequently, orbital support was achieved with well-vascularized, thin, strong fascia with smooth surface. Right facial artery and vein were chosen as recipient vessel. Duration of the operation was 5.5 hours. Postoperative period was uneventful. Six months after the surgery, the right eye was in good position without inferior dystopia. Eyeball movement could be done without restriction. The patient also denied diplopia. Reconstruction of globe-sparing total maxillectomy defects with free RAM flap with anterior rectus sheath has several advantages that enable the reconstructive surgeon to solve the multiple complex reconstructive task with one flap: 1) elimination of the secondary donor site morbidity; 2) more simply addressing the challenging task of the eye support than the other techniques; 3) obliterating the maxillectomy defect and closing the palate; 4) restoring the large skin defect; and 5) reducing the operation time. It is difficult to conclude that this technique is the best choice in such cases based on a report of the single case. However, presented technique should be kept in mind as a practical and effective reconstructive option in cases that have underwent the total maxillectomy with the preservation of the orbit.

Reconstruction of a full-thickness cheek defect, especially one associated with a large lip and oral commissure defect, remains a challenge. After tumor excision, replacement of the oral mucosa is often necessary. The oral mucosa is a thin, pliable lining. Because the skin of the forearm is ideally suited for replacement of oral lining, being thin, pliable, and predominantly hairless, the radial forearm flap is the most frequently used soft-tissue flap for this purpose. In addition, the vascularity of the area allows substantial variation in the design of the flap, both in relation to its site and size. On the other hand, the radial forearm flap might be unusable in some occasions, such as in the case presented here. Thus, a search for an alternative free flap is required. We used a prefabricated scapular free flap to reconstruct a large concomitant lip and full-thickness cheek defect resulting from perioral cancer ablation. We introduce a new "opened pocket" method for reconstruction of the intra-oral lining without folding the flap. Resection of the tumor resulted in a defect including 45% of the upper lip, 50% of the lower lip, and a large, full-thickness defect of the cheek. The resultant defect was temporarily closed with a split-thickness skin graft. Meanwhile, the left scapular fasciocutaneous flap was prefabricated for permanent closure of the defect. The left scapular flap was outlined horizontally, and the flap orientation for the defect was estimated. Then, the distal portion of the flap was harvested and incised to create lips and oral commissure. Afterward, the raw surface under the neo-lip regions and the base where the flap was raised was grafted with one piece from a thick, split-thickness skin graft. Fourteen days later, the patient was taken back to the operating room for reconstruction of the defect with free transfer of a prefabricated scapular fascia-cutaneous flap. The grafted distal region of the flap was raised with the deep fascia located under the graft. Thus, a pocket was obtained. The flap was placed in the defect for final tailoring. Mucosal defect was evaluated to decide where the pocket was to be opened. Then, the grafted fascial portion of the flap was incised from the free edge to the neocommissure. Consequently, lower and upper lip mucosa were achieved by opening the pocket. The prefabricated flap was adapted to the defect with the appropriate sutures. The superior thyroid artery and internal jugular vein were used as recipient vessels. The postoperative period was uneventful. There were no healing problems of the suture lines of the opened pocket, and both labial sulci were quite adequate. The patient was able to resume a soft diet 10 days after the operation. She also had a satisfactory oral competence and an acceptable appearance, without microstomia. Despite its disadvantages, prefabrication can make the scapular fascia-cutaneous flap suitable for reconstruction of a large, concomitant lip and full-thickness cheek defect when other more appropriate flaps are not available. Th...

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