Schematic drawing of radial forearm flap showing the relation of the palmaris longus tendon, cephalic vein, the lateral antebrachial cutaneus nerve (LABC), and the arterial pedicle.
Schematic drawing of flap insert.
Postoperative result following total lip and chin resection and surgical reconstruction with composite radial forearm—palmaris longus tendon free flap.
Carroll CMA, Pathak I, Irish J, Neligan PC, Gullane PJ. Reconstruction of Total Lower Lip and Chin Defects Using the Composite Radial Forearm—Palmaris Longus Tendon Free Flap. Arch Facial Plast Surg. 2000;2(1):53-56. doi:
From the Head and Neck Program, Departments of Otolaryngology (Drs Carroll, Pathak, Irish, and Gullane) and Plastic Surgery (Dr Neligan), The Toronto General Hospital, University of Toronto, Toronto, Ontario.
Background Functional and aesthetic restoration of total lip and chin defects can be achieved using the composite radial forearm—palmaris longus tendon free flap.
Objective To present the technique we use and our experience with this form of reconstruction in 10 consecutive patients with total lip and chin defects who were surgically treated between 1992 and 1998.
Methods The palmaris longus tendon acting as a sling over which the flap is draped is responsible for long-term maintenance of vertical lip height and lip support. The factors responsible for this are the long-term maintenance of vertical lip height and lip support and the transfer of facial muscle activity to the neolip.
Results All patients were satisfied with their final reconstructive result.Oral competence for deglutition and speech was achieved in all patients in our case series, with no incidence of drooling.
Conclusion We recommend the use of the composite radial forearm—palmaris longus tendon free flap for this type of reconstructive surgery.
FUNCTIONAL and aesthetic restoration of the lips following surgical resection has long been a reconstructive challenge for the surgeon. Most of the techniques used to restore lip continuity evolved in the early 1800s and were refined in the 1900s.1 The lips, dominating the lower third of the face, are a complex anatomical structure composed of skin, intrinsic and extrinsic muscle, and mucosa.2 The intrinsic muscle of the lips, the orbicularis oris through its sphincteric action gives rise to oral competence and the extrinsic facial muscles that insert into the lips allow for speech modulation and the whole range of facial expression.
The lips can be divided into several aesthetic subunits. The upper lip is divided into 3 subunits—2 lateral subunits and 1 medial subunit, the philtrum. The lower lip is divided into 1 subunit. The nasolabial crease separates the upper and lower lips from the cheeks and the labiomental crease separates the lower lip from the chin. The goals of lip reconstruction therefore should be to restore the complex function and form of this anatomical unit. The end result should achieve a competent oral sphincter that is sensate and of adequate diameter. There should be complete skin cover, oral lining, and the semblance of a vermilion.
The site and size of the defect ultimately determines the feasibility of achieving these goals. Lip defects less than one third in size can be closed directly. Defects greater than one third require the import of new tissue. This new tissue can be burrowed from the remaining lip, the opposite lip, or the adjacent cheek, or local flaps may be used. Once the defect involves the whole lower lip and extends onto the chin it is necessary to consider distant flaps.
The composite radial forearm—palmaris longus tendon free flap has been described by Sakai et al,3 as a new technique for reconstructing total lip and chin defects. We report our experience with this form of reconstruction in 10 consecutive patients surgically treated between 1992 and 1998 at the Department of Otolaryngology, Head and Neck Program, The Toronto General Hospital, Toronto, Ontario.
Ten consecutive patients were surgically reconstructed with a composite radial forearm—palmaris longus tendon free flap following total lip and chin resection between 1992 and 1998. All patients were male and aged from 45 to 96 years. Patient characteristics are given in Table 1.
A template of the proposed defect is fashioned before surgical resection. The height of the cutaneous and mucosal aspects of the lip are measured and recorded. The flap is designed so that it could be draped over the palmaris longus tendon. To achieve this the template is positioned on the donor forearm site so that the proposed cephalic margin of the reconstructed lip lies over the palmaris longus tendon. The flap is elevated in a standard fashion.4 It includes 2 venous systems, the venae commitantes of the radial artery and a major branch in the superficial system to either the cephalic or the basilic vein, 1 antebrachial cutaneous nerve, and the palmaris longus tendon (Figure 1). The proximal and distal ends of the palmaris longus tendon are transected 2 cm from the flap. When the palmaris longus tendon is absent, the flexor carpi radialis tendon is harvested instead. In our case series 2 patients (patients 1 and 4, Table 1) also had radial bone incorporated in their flaps for mandibular reconstruction.5-6
The flap is transferred to the recipient site and inset following tumor ablation and appropriate neck dissection (Figure 2). The flap is draped over the palmaris longus tendon sling and lip height is restored using the measurements taken before surgical resection. We usually overcorrect both the external and internal height by 5 mm, which compensates for future flap contraction. The cut ends of the palmaris longus tendon are sutured while being stretched to the facial muscles in the region of the modiolus bilaterally using nonabsorbable suture material. The tendon should be stretched tight enough to maintain lower lip support but not "bowstrung," as this will lead to future lip entropion. The microneural anastomosis is performed between the antebrachial nerve and the cut end of the mental nerve. Finally the microvascular anastomosis is performed according to available vessels.
Standard postoperative care was carried out and patients fed by nasogastric tube for an average of 8 days postoperatively.
There were no composite radial forearm—palmaris longus tendon free flap failures in this case series of 10 patients. One patient (patient 2, Table 1) developed a cervical wound dehiscence on day 6 that required reconstruction with a pectoralis major myocutaneous flap. One patient (patient 3, Table 1), whose ablation included a segmental mandibulectomy with plate reconstruction, developed plate exposure at 10 months.
Restoration of oral competence for both speech and deglutition was achieved in all 10 patients, with no incidence of drooling. One patient (patient 1, Table 1) developed lower lip entropion at 6 months postoperatively. This did not cause any significant functional deficit and the patient did not wish to undergo further surgical reconstruction. One patient (patient 5, Table 1) required long-term nasogastric tube feeding to supplement his oral intake. This patient had underlying tardive dyskinesia secondary to receiving antipsychotic medication. This contributed to his inability to maintain his full dietary requirements by mouth.
All patients were satisfied with their final reconstructive appearance (Figure 3).
Surgical reconstruction of total lower lip and chin defects because of their large size require reconstruction with distant flaps. As cited by Mazzola and Lupo,7(p585) historically submandibular flaps were used by Lallemand in 1824. They also report that Delpech used a large superiorly based anterior cervical flap to achieve both lining and cover.7(p585) Delpech describes rotating the flap 180° into the lower lip defect which was then folded on itself. The introduction of the deltopectoral flap as described by Bakamijan8 in the 1960s provided a more reliable method of reconstructing these defects; however, this required 2 stages. O' Brien9 described the use of pedicled myocutaneous flaps for the reconstruction of extensive lower lip defects in the 1970s using the sternocleidomatoid myocutaneous flap. Charles et al,10 reported their experience with this form of surgical reconstruction in 27 patients. One of the significant problems they noted was donor-site morbidity. The pectoralis major myocutaneous flap is another reconstructive option; however, lack of sensation and lack of function is common to all pedicled flaps used to reconstruct this type of defect. Sakai et al,3 introduced the concept of free tissue transfer for surgical reconstruction of total lip and chin defects in 1989. They described one case in which they had successfully used the composite radial forearm—palmaris longus tendon free flap. The palmaris longus tendon was incorporated into the flap and used as a sling to support the neolip. Sadove et al,11 used this flap in 4 more patients and reported their results in 1991. Serletti et al12 reported another case in 1997 and discussed their refinements of the surgical technique. Since 1992 we have successfully used this form of surgical reconstruction in 10 consecutive patients with total lip and chin defects.
The composite radial forearm—palmaris longus tendon free flap has many advantages over pedicled flaps when used for reconstruction of total lip and chin defects. The use of this form of surgical reconstruction allows for a single-stage procedure that results in complete skin cover and oral lining. The large amount of skin that can be raised with the radial forearm flap always results in patients having an adequate stomal size, as we found in our case series. Patients requiring segmental mandibulectomy as part of their ablation can have bony continuity restored by incorporating radial bone into the flap as we did in 2 patients.
Oral competence for deglutition and speech was achieved in all 10 patients in our case series, with no incidence of drooling. The factors responsible for this are the long-term maintenance of vertical lip height, lip support, and the transfer of facial muscle activity to the neolip. The palmaris longus tendon acting as a sling over which the flap is draped is responsible for maintaining vertical lip height and lip support. When the palmaris longus tendon is absent then the flexor carpi radialis tendon can be harvested instead. Accurate measurement of both the external and internal components of vertical lip height are taken before surgical resection and are used when insetting the flap. We add 1 mm to the internal height measurement and 2 mm to the external height measurement to allow for flap contraction over time. The tension under which the palmaris longus tendon is inset is an important technical factor. If the palmaris longus tendon is inset too tightly this will eventually lead to entropion of the reconstructed lip as occurred in 1 patient early on in our case series. When the palmaris longus tendon is inset under too little tension, lip ectropion will result. Although this flap is not a dynamic one, animation of the neolip does occur. The suturing of the palmaris longus tendon under adequate tension to the facial musculature at the modioli allows muscle action from the remaining extrinsic facial muscles to be transferred to the neolip. We believe that securing the palmaris longus tendon to the malar eminence as described by Serletti et al12 reduces the amount of facial muscle activity that is transferred to the neolip. We stopped doing this early on in our case series.
Neurotization of the flap creates a sensate neolip. Subjective recovery of sensation in the neolip was reported by all 10 patients in our case series. We did not confirm this by objective methods.
Aesthetically there is a reasonable color match between the radial flap and surrounding facial skin and by respecting the aesthetic subunits during surgical resection and reconstructive planning, the eventual cosmetic result is further enhanced. We did not try to reconstruct the vermilion in this group of patients. Sadove et al11 recommend vermilion reconstruction using the Mc Gregor tongue flap13 at the primary surgery. Medical tattooing is another option that can be offered to the patient at a later stage. Postoperatively we also noted mild flap edema as reported by Sadove et al in their series of patients. This edema resolved after 3 to 4 months in all of our patients. All patients in this case series were satisfied with the final result of their reconstruction.
The composite radial forearm—palmaris longus tendon free flap was initially reported for use in surgically reconstructing total lip and chin defects by Sakai et al3 in 1989. Since 1992 we have used this form of surgical reconstruction in 10 patients and had no composite radial forearm—palmaris longus tendon free flap complications. It is an easy flap to harvest and inset. Long-term maintenance of vertical lip height and lip support can be achieved by suturing the cut ends of the palmaris longus tendon into the modiloi. The flap provided appropriate cover, lining, and lip support in all 10 patients. Stomal size was adequate in all patients; none experienced drooling. All patients were satisfied with their final reconstructive result. We believe that the composite radial forearm—palmaris longus tendon free flap is the flap of first choice for surgically reconstructing total lip and chin defects.
Accepted for publication November 16, 1999.
Corresponding author: Patrick J. Gullane, MD, Head and Neck Program, Department of Otolaryngology, The Toronto General Hospital, 200 Elizabeth St, 7EN- 242, Toronto, Ontario, Canada M5G 1H4 (e-mail: firstname.lastname@example.org).