Reconstruction of Large Defects of the Lips and Commissure Using a Composite Radial Forearm Palmaris Longus Free Flap Associated With a Lengthening Temporalis Myoplasty

Abstract

We performed a single-stage operation to reconstruct a large defect of the lips and commissure using a composite radial forearm-palmaris longus free flap. To obtain cranial traction and a voluntary smile, independently from any jaw movement, traction was achieved by using a lengthening temporalis myoplasty. The tendon attached to the coronoid process was fixed to the palmaris longus tendon, recreating a new commissure and a "neo-modiolus." Physical therapy was started on the 21st postoperative day to facilitate progress from a "mandibular smile," to ideally a spontaneous and symmetric smile after 3 months of therapy. This procedure was able to obtain good oral continence and a good commissural movement during smile which has not previously been mentioned in the published literature.

Composite pronator quadratus: radial forearm free flap in functional lip reconstruction

“…Deformity and functional losses as a result of the defect or inadequate reconstruction are often associated with physiological and psychological distress . General goals in lip reconstruction include maintenance of oral competence, mucosal and skin coverage, acceptable aesthetic appearance, mobility, maximal oral aperture and sensation …”

“…Local flaps can provide functional muscle and soft tissue for large lip defects of up to 80%. Local flaps in larger or more complex defects are associated with deformity, and microstomia . Larger defects therefore necessitate microvascular reconstruction to avoid these complications …”

“…Functional muscle flaps have been trialled as an alternative technique to address these limitations. The gracilis muscle flap in particular has been a popular option in recent times, with its success in other sphincteric reconstructions (anal sphincter reconstruction) noted in the literature . The functional results with the gracilis flap have been generally positive .…”

One-stage through-and-through cheek, lips, and oral commissure reconstruction using a double-paddle peroneal chimeric flap: An innovative method

“…To avoid the drawbacks of a local flap, the reconstruction of large defects involving the cheek, lips, and oral commissure often requires a free flap or even 2 free flaps . The radial forearm free flap and its refinements have been reported with acceptable results . Although it is thin and versatile for restoring three‐dimensional oral and lip defects, radial forearm free flaps are insufficient for replacing large through‐and‐through cheek and bony defects.…”

“…A 1‐piece flap folded into the oral commissure is usually used to restore through‐and‐through cheek defects involving the oral commissure and lips. A suspension techniques, either static or dynamic, combined with 1‐piece flap reconstruction has been introduced to create better lips and oral commissure with a one‐stage operation . Unfortunately, a rounded oral commissure and unnatural commissure position still lead to drooling and oral incompetence that require additional revision.…”