The Use of Radial Forearm Free Flap for Total Lower Lip Reconstruction:The Analysis of 10 Consequentive Cases and Quality of Life Evaluation

Postresection defect of the total lip, especially when it is associated with regional tissues i.e. cheek skin, floor of the mouth, mandible, presents a real challenge for reconstructive surgeon. For total lip recreation many different techniques can be considered. Microvascular free tissue transfer is the latest major advance in lower lip reconstructions and the main contributing factor in the quality of life improvement. The modern techniques are able to deliver well-vascularised tissues to allow closure of even most complex and extended postresection defects. The aim of lip restoration is to provide proper oral lining and external cheek skin and to reconstruct oral competence. There are several issues in lower lip reconstruction using microvascular tissues that must be considered, including defect's size, aesthetic units, support, recreation of the vermillion and defects of associated tissues. Among many certain donor sites the radial forearm free flap (RFFF) has become a golden standard for majority of patients with total lip postresection defects, especially in cases where the use of local techniques may result in functional and/or aesthetic loss [1].

RFFF provides thin, pliable fasciocutaneous tissue for intra- and extra oral defects. This particular free flap is highly reliable because of large diameter of its artery and veins. The vascular pedicle is ideal with long vessels capable to reach the opposite side of the neck if necessary [5]. That characteristic makes it a useful one for lower face postresection defects reconstruction.

The aim of this paper is to present the group of 10 consecutive patients with lower lip cancer, who underwent the RFFF reconstruction to develop a precise, based on anatomical details, plan of incorporating radial forearm free flap in lower lip reconstruction. Qualities of life, mainly aesthetic and functional results are also analyzed.

Material: From March 2002 to December 2005, 10 consecutive patients with squamous cell cancer of the lower lip, underwent complex surgical treatment in the Dept. of Surgical Oncology in Cancer Center MSC Memorial Institute, Gliwice, Poland. The only eligible criterion was the use of radial forearm free flaps for lower lip reconstruction. All reconstructive procedures were performed at the time of resection. None of the patients underwent second corrections.

There were 8 men and 2 women, and M:F ratio was 4:1. The average age was 56 years. In whole group cancer was in advanced stage (T 3/4).

Methods: All patients underwent surgical resection of primary tumor en block with regional neck nodes. Type of lymph nodes dissection was adequate to the stage of disease. In all cases wide local resection were performed. Technique of the reconstruction was chosen individually, based on type and localization of postresection defect, general patient's condition and his expectations as well. In all cases radial fasciocutaneous forearm free flap was chosen. Volume and location of soft tissue loss directly forced the size and shape of skin paddle. The size of skin island corresponded with the contour of the postresection defect. In all cases a template duplicated the defect was made. The extraoral defects varied from 18 to 45 cm² and the intaoral were between 15 and 30 cm². In 3 cases the marginal mandibulectomy was performed. In 7 cases the flap was harvested with the palmaris longus tendon crossing the internal surface. In 4 cases the tendon was sutured to the deep surface of the oral commissures and in remaining 3 cases (were resection was more extended) it was attached to the zygomatic arches.

In 4 cases the RFFF was associated with antebrachal sensitive nerve which was anastomosed to menthal nerve stump. The detailed characteristic of the material is presented in Table 1.

Table 1: Characteristic of the clinical material.

The vascular pedicle length varied from 10 to 16 cm. In 8 cases arterial anastomoses were performed with facial artery end to end and in remaining 2 with thyroid superior. In about 70% RFFF single vein (concomitant) was connected with jugular internal or facial vain and in the remaining 30% two veins were simultaneously anastomized.

In all cases split-thickness skin grafts were used for donor site closure (taken from the thigh). In 8 cases radial forearm free flap was used alone (Figure 1a,b, 2 a,b) and in two cases the RFFF was combined with fibula free flap due to mandible infiltration (Figure 3 a,b). In those cases osteoseptocutaeous free fibula was able to reconstruct the segment of the mandible and its skin island was used to recreate the oral vestibule and floor of the mouth.

Figure 1: a,b – Pre- and postoperative view of patient – the use of RFFF with tendon lip suspension.

Figure 2: a,b – The steps of total lip reconstruction with RFFF.

Figure 3: a,b – The use of double independent free flaps – radial forearm for lip and fibula for mandible reconstruction.

Quality of life evaluation: There are still too little studies on the QOL of patients after microvascular reconstructions for lower lip cancer. This is the reason why we recently introduce the routine practice to own questionnaire of functional and aesthetic outcome after combined surgery (resection + reconstruction) for all patients reconstruction outcome, that means aesthetic and functional results have been quantified using own Quality Of Life Questionnaires. The questionnaire takes into account the impact of surgical procedures on the QOL in relation to a radial forearm free flap for lower lip reconstruction. Eight-item scale includes measures of symmetry, vermillon shape, size and contour of the recreated lip, the status of postoperative scars and functional results such as: lip mobility, oral closure, articulation and presence of the microstomia. Each parameter was considered as good (1) or bad (0). Every patient answered once to this questionnaire, i.e. 6 months after surgery (Table 2).

Table 2: QOL questionairre and results.

The patients are interviewed by the QOL Office (sociologists and physiologists) independently of the treatment team. The present analysis includes small number of cases which can be considered only as a preliminary report.

In the whole group of 10 patients tumor resection was radical and surgical margins were histopathologically negative. Actuarial 12-months recurrence-free survival is 100%.

10 flaps were successfully transferred (100%). Two flaps were explored within 24 hours after surgery, because of vein thrombosis and two was salvaged. One patient developed postoperative fistula in submandibular region which required surgical retreatment with successful outcome. In one case (after flap salvage surgery) partial flap loss (smaller than 30%) occurred. There were no donor site complications except two cases were skin graft partial loss was noted (requiring second regrafting).

According to quality of life assessment the material was subdivided into two groups, based on postressective defect volume (Gr. A- 30-60 cm², Gr. B-> 60 cm²). Both aesthetic and functional outcome were better in Group A than in Group B (70 vs 50 points). Quality of life analysis did not show any differences between different modalities of lip suspension (palmaris longus tendon - zygomatic arch vs palmaris longus tendon - orbicularis oris muscle). Moreover better results were noticed in patients were no lip suspension was performed.

Complete oral competence was achieved in all but one patient (the largest defect with marginal mandibulectomy). The type of lip suspension except one case did not affect the speech and articulation function. None of patients presented microstomia. Detailed QOL results are presented in Table 3.

Table 3: Aesthetic and functional results according to defect size and type of lip suspension.

Although the results of reinnervation were not analyzed, no subjective differences were noticed between 4 cases were antebrachial was anastomosed with menthal nerve and cases were no sensate recreation was performed.

The lips play an important role in facial expression, speech and eating. To achieve optimal functional and aesthetic outcome a significant attention must be put to make a right plan of both resection and reconstruction. Although for total lip defects many different methods have been suggested, the introduction of microvascular techniques allowed for single stage reconstruction of a complex and extended tissue loss. Among many techniques the radial forearm free flap is the most commonly used for soft tissue defect only. It provides a decent support especially when it is transferred with palmaris longus tendon. In different authors opinion the tendon can be sutured to either nasolabial area, the malar periostium, or to the bilateral modiolus. Those variations allow reconstruct a static suspension only. Recently, Sawhney [2] proposed the technique of dynamic suspension, where the tendon is connected to transferred masseter muscle. Jeng et al. [3] reported the principles of looping the palmaris longus tendon to orbicularis oris muscle. Our experiences show that this technique of tendon fixation is able to restore complete circumference of oral sphincter. Moreover, this variant of dynamic reconstruction is an easy, one stage procedure providing similar functional outcome comparing to cases where the tendon was sutured to zygomatic arches [4-6]. In our limited data the results show only the idea of different radial flap modalities influencing the quality of life outcome and therefore it is presented as preliminary report. The QOL analysis presents no differences between static and dynamic lip suspension. It can be explained by careful choice of suturing the palmaris longus tendon to zygomatic arch or orbicularis oris muscle due to the size of postressective defect volume and extension. In cases were the defect was relatively small and limited to lower lip only, no suspension was performed with good functional and aesthetic results. In very thin patient the flap is sometimes to thin and does not provide bulk. This can be overcome with a brachiradialis muscle being harvested with the skin flap to add bulk. For bulky flaps secondary thinning in the appropriate zones with liposuction will improve the aesthetics and the use of fat injection is also of value secondary bulking of the neo-lip [7,8]. From aesthetic point of view the use of distant flaps i.e. radial forearm gives the color mismatch and according to forearm anatomy, bulk can decrease the aesthetic outcome. Therefore the flap thinning or second procedures are often required. In our series after harvesting and detaching the flap was individually thinned when necessary, with no second procedures. In 8 of 10 cases the proper lip symmetry was achieved, and in more than half of the patients size of the lip and its contour, with good status of scars were noticed [9,10].

In our series there were no differences in sensation whether the menthal nerve was anastomosed with antebrachial nerve or not. It can be explained by short period of observation and small group of analyzed patients and on the other hand by difficulties of comparing the sensate recreation coming from anastomosing the menthal and antebrachial nerve and spontaneous reinnervation itself [11].

Conclusions

Our experience with free radial forearm free flap for total lip reconstruction suggests that the careful and detailed planning of the size, shape and type of lip suspension influence both functional and aesthetic results. Static lip suspension for defects limited to lower lip only is comparable to dynamic suspension in cases where the defect is complex and extended. Results of quality of life analysis may be a predictive factor influencing the choice of individual flap modification including the type of lip suspension.