Chin IX: Unusual Soft Tissue Problems of the Lower Face

Abstract

When the editor asked me to write something related to the chin, I (B.M.Z.) told him I would like to concentrate on the soft tissue of the perioral and chin region, something previously not presented before in this Journal specifically or anywhere. Dr. Flores and I have chosen certain soft tissue cases of the lower face, each of which presents certain dilemmas. The reconstructive methods in each case are unique, previously not shown, and represent salvage from prior failures. Case 1 shows how an interior Abbe flap can be used for ipsilateral lip reconstruction. Case 2 shows how a large upper lateral lip elemental loss can be regained from cheek and not the lower lip. Cases 3 and 4 show how to regain proper white roll bulge and symmetry by overcorrection, then exact adjustment in a second stage. Case 5 shows how a failed chin/lip reconstruction can be salvaged to regain sulcus height and aesthetic unit reconstruction. Each case depicts unique reconstructive designs to produce an aesthetic final result.

Case 1: Port-Wine Stain Macrocheilia Overresected—Where do You Get Tissue?

The first case was a 25-year-old female nurse with a history of lower-lip port-wine stain macrocheilia. An outside surgeon reduced her lip by horizontal excision of the vermillion, resulting in an irregular contour of the lower lip with incisor show on the left (Figure 1). The commissure to commissure distance was excessive.

Problems

• Deficiency of the vermillion on the left side of the lower lip.
• Excess horizontal length of the lower lip.
• Incisor show.

Reconstructive Plan

4.

Restoration of the left lower-lip vermillion deficit with an ipsilateral, interior, Abbe flap transposed 90 degrees to the left.

5.

Resection of excess horizontal lower lip and donor defect from Stage 1.

Stage 1

Deficient left lower-lip vermillion was restored by trans- ferring an anteriorly based mucomuscular flap from the central lower lip, 90 degrees toward the left into the lower wet-line. The wedge-shaped central lip flap in- cluded vermillion and muscle, extending all the way to the sulcus. A horizontal incision made behind the wet line of the left lower lip allowed for reception, augmen- tation, and lifting this deficient area while preserving texture to the vermillion. Transposition of the central lip flap resulted in restoration of bulk to the left lower lip and a central lower cleft at the midline (Figure 2).

Stage 2

A double-barrel wedge resection of the central lower lip simultaneously reduced the horizontal lower-lip excess and removed the whistling deformity created by the previous operation (Figure 3). Debulking of the excess lower-lip vermillion was also performed at this stage.

Result

Contour was improved to the lower-lip vermillion, with elimination of horizontal lower-lip excess and no incisor show (Figure 4A,B).

Port-wine vascular malformations of the lower lip cause enlargement in the horizontal and vertical planes, and they may continue to enlarge after correction. Surgical interventions must correct the tissue excess in three dimensions [1]. Failure to correct port-wine stain– induced lip expansion in the horizontal dimension left the patient with lip droop, vermillion loss, and a long lip horizontally.

In the first stage, a previously undescribed, pos- terior variation of the Abbe flap was used. In its classic description, Abbe flap borrows full-thickness anterior lower lip to restore upper-lip defects. In this case, a partial-thickness interior Abbe is transposed to the ipsi- lateral lip, creating a central lower-lip cleft. A double- barrel excision of the horizontal lip excess concurrently removed the central lip deformity.

Case 2: Expanding the Reach of the Deep-Plane Schrudde Flap

Case 2 was a 58-year-old woman with recurrent mor- pheaform basal cell carcinoma excised by Mohs micro- graphic surgery (Figure 5). The resulting full-thickness defect measured 3.5 × 2 cm and encompassed the infer- omedial right cheek and superolateral aspect of the right upper-lip skin. The defect was covered with a full- thickness skin graft (FTSG) by an outside surgeon and the lining was closed primarily, leaving the patient with a ‘‘crater’’ deformity and a sneer (Figure 6). The patient also complained of persistent drooling due to retraction of the right upper lip. The patient refused a lower-lip scar to reconstruct the upper lip.

Problems

• Large upper-lip soft tissue defect extending onto the cheek with mucosal and skin deficiency.
• Upper-lip retraction.

Reconstructive Plan

• Deep-plane angle-rotation flap to restore the upper- lip defect (Figure 7).

Stage 1

The previously placed FTSG was excised, recreating the defect, and an intraoral transposition mucosal flap cor- rected the lining defect so the angle-rotation (Schrudde) flap was elevated in the deep plane to cover the upper-lip defect with the cheek flap. The deep plane was used to maximize the blood flow, and therefore success of the flap, but Pribaz [2] has shown that a deep-plane dissection may not be required. Resection of the most medial aspect of the defect was performed by a partial-thickness wedge resection of the upper lip to reduce the medial defect size and allow the flap to move down properly (Figure 7). The Schrudde flap [3] was elevated in the subcutaneous plane below and behind the ear and in the deep plane across the face (Figure 8). The flap rotated medially, and inferiorly covered the resulting defect. To prevent ectropion and descent of the flap, the deep dermis of the flap was attached to the periosteum of the malar eminence and the pyriform aperture.

Stage 2

Stage 2 entailed debulking of the Schrudde flap over nasolabial fold and along the inferomedial aspect of the incision line.

Result

The patient’s cheek concavity was removed, her sneer was alleviated, and she no longer drooled. Scars were placed along the unit borders of the face, and there was a good color and texture match to the cheek (Figure 9 and Figure 10).

The Schrudde flap has the advantage of supplying a large area of cheek and neck skin to reconstruct defects of the cheek while not leaving any scars on the neck and chest, and it may be readvanced in future reconstruction, especially well noted by Joel Feldman (B. Zide, personal communication) [2,3]. The cheek and neck skin provide an ideal color and texture match for cheek defects. The resulting scars lie in the aesthetic unit borders of the cheek with the upper lip, nose, lower lid, and ear. The sub-/postauricular scar is well hidden behind the ear. The posterior auricular triangle design allows for medial rotation of the flap through primary closure of the triangle defect. The fixation of the neck skin to the inferior conchal cartilage skin relieves the tension in the neck. Flap suspension to the periorbital area is critical in preventing traction of the lower lid and descent of the flap over time. The Schrudde flap was originally de- signed in the subcutaneous plane, but the deep plane increases its reliability [2,4,5]. The senior author always uses the deep plane for medial suborbital and lip defects. This flap has been traditionally used to cover large defects in the lower eyelid and cheek [2,3]. As noted before, the use of this flap to cover a defect affecting the upper lip was also described by Pribaz [2]. As the aesthetic junction of the cheek to upper lip is violated by this technique, the nasolabial depression can be created at the second-stage operation by debulking the area of the nasolabial fold as well as the alar-facial junction. The normal lip, just lateral to the alar-facial groove, must be flat. When advancing the cheek element medially, this flat contour must be recreated by defatting the corresponding area of the cheek flap to create a planar surface.

There are other reconstructive options available for large defects of the upper lip. If greater than 50% of the upper-lip subunit is missing, the entire subunit may be replaced by a large Abbe flap templated from the normal side as described by Burget and Menick [6]. Alter- natively, a V-Y flap of nasolabial tissue, as described by Yotsuyanagi et al., may be templated from the normal upper lip and advanced into the defect, reconstructing the subunit in its entirely [7]. The Yotsuyanagi method requires an intact facial artery, which was not present in this patient.

Cases 3 and 4: Precise Reconstruction of the White-Roll

Case 3

Case 3 was a 23-year-old woman who presented after substance loss of the lower-lip vermillion/skin junction by a dog bite. The original lesion located on the subunit border was closed primarily, advancing the vermillion beyond the border of the white roll (Figure 11).

Problems

• Obliteration of the white roll.
• Advancement of the vermillion onto the lower-lip skin.

Reconstructive Plan

• Reconstruction of the vermillion/lower-lip skin bor- der exactly with a skin graft.

Stage 1

Excision of the scarred area created a 3 × 1-cm defect. A slightly oversized full-thickness preauricular skin graft was inset by basting and suture (no bolster) of 4–0 Vicryl Rapide (Ethicon, Somerville, NJ) and 5–0 Vicryl Rap-ide. The inset of the skin graft encroached slightly onto the inferior vermillion to compensate for future contrac- tion of the graft (Figure 12).

Stage 2

After 4 months, excess skin graft in the area of the vermillion was de-epithelialized to form the white roll bump and the vermillion advanced over the dermis of the graft to form the white roll precisely (Figure 13). Dermab- rasion of the graft edges is planned.

Result

We achieved restoration of balance to the lower lip by precise reconstruction of the white roll.

Case 4

Case 4 was a 17-year-old woman, who sustained an electrical burn to her left upper and lower lip and commissure as a child. She had previously undergone reparative surgery to her lip with minimal improvement.

Problems (Figure 14)

• Deficiency of upper-lip vermillion lateral to left Cupid’s peak.
• Left lower-lip white roll disrupted.
• Left lower-lip vermillion extending into rounded commissure.
• Contracture of left commissure.
• Tethering of the mucosa posterior to the left com- missure.

Reconstructive Plan

• Composite graft from right lower lip to left upper lip to equilibrate the vermillion.
• Excision of excess left upper-lip skin.
• Two-stage left lower-lip white roll reconstruction with an FTSG graft.
• Excision of scarred mucosa and commissure release followed by local flap reconstruction.

Stage 1 (Figure 15)

After scar removal, composite graft of mucosa and sub- mucosa from the right lower lip was placed into the deficient left upper lip through an incision at the wet line. The left upper-lip border was moved superiorly by excision of poor upper-lip skin, based on a template taken from the right upper lip. The scarred left lower lip was excised, and a slightly oversized FTSG was taken from the preauricular area and inset into the defect. The skin graft extended slightly onto the area of the vermil- lion to compensate for future contraction of the skin graft (Figure 16). The scarred intraoral mucosa was excised, and the resulting defect was closed with local mucosal flaps.

Stage 2

Excess composite flap to the left upper lip was reduced. Excess FTSG was de-epithelialized superiorly, and the vermillion was advanced, reconstructing the white roll exactly (Figure 17 and Figure 18).

Discrepancies of 1 mm in the white roll are observable in conversational distance. The most accurate way to use a skin graft to reconstruct the white roll seems to be this simple, two-staged technique. With this technique, the surgeon does not worry about contrac- tion. The defect is recreated and a slightly oversized FTSG taken from the preauricular area is inset into the area of the vermillion. For defects of the lip, grafts from the preauricular area or the superolateral forehead pro- vide better color and texture match than the neck or postauricular skin. After a period of at least 4 months, contraction seems completed. In the second stage, excess skin graft is de-epithelialized (for white roll) and the vermillion advanced over the skin graft to reconstruct the white roll in its precise location. Dermabrasion may be used in a third stage to blend the borders of the skin graft with the surrounding skin.

Case 5: Gunshot Loss to Lip and Chin

Case 5 was 23-year-old male with a history of a gunshot wound to the central mandible previously reconstructed with a fibula and radial forearm free flap. Prosthetic lower dentition with implant was also placed. Although the patient did have successful bony reconstruction, his soft tissue coverage had several inadequacies (Figure 19, Figure 20 and Figure 21).

Problems

• Scarred lower gingivobuccal sulcus resulting in labial incompetence: excessive lower incisor show and per- sistent drooling, requiring him to wear a bib.
• No labiomental sulcus (Figure 20).
• Lack of a chin prominence (Figure 21).
• Subunits of the lower lip and chin disrupted by a patchwork appearance (Figure 19).
• Scarring on the neck and chin from prior flaps.
• Inadequate vermillion.

Reconstructive Plan

• Restoration of the sulcus lining with a thrice delayed extraoral to intraoral turnover flap from the lower-lip skin.
• Formation of a labiomental sulcus.
• Decreased bulking of the chin pad with advanced de- epithelialized submental tissue.
• Resurfacing the lower-lip skin with a second radial forearm flap.
• Restoration of vermillion bulk with a tongue flap.

Stage 1

To transpose extraoral tissue for lining to the inside of the mouth, a full-thickness separation of the vermillion and lower lip was made from commissure to commissure (Figure 22). The incision provided access to the deficient intraoral lining while still respecting the subunit border of the vermillion and lower lip. The raw surface of the composite bipedicle flap of vermillion, orbicularis oris, and mucosa was temporarily covered with Biobrane (UDL Laboratories, Rockford, IL). The superior cut edge of the lower-lip skin was sutured to the scarred intraoral sulcus.

Stage 2

A turnover flap from the superior segment of the forearm flap was delayed three times (partial incision, full incision, then undermining) for planned turnover into the oral cavity to restore lining (Figure 23). Interestingly, the patient had full control of the bipedicled mucosomuscular ver- million flap and could lift it at will, demonstrating good facial nerve function to the lower-lip composite flap.

Stage 3

The vermillion was split at the lower midline, and the turnover flap was inset into the intraoral lining defect, restoring the deficient sulcus height (Figure 24). A second radial forearm flap was used to cover the lower-lip subunit almost to its entirety (Figure 25). The flap was slightly short at the right commissure. At this point, patchwork effect of the lower-lip chin was eliminated but the patient still lacked chin prominence and a labiomental fold and had only fair vermillion bulk.

Stage 4 (Several Procedures)

The inferior aspect of the old radial forearm flap (under the menton) was de-epithelialized and advanced under the skin overlying the pogonion to increase prominence. The sides of the forearm flap were defat- ted. A labiomental fold was recreated by an incision with debulking of the area of the submental fold. Z-plasties were done on the left neck.

Stage 5A and B

An anteriorly based tongue flap was brought to right side to add bulk to the vermillion and was separated after 2½ weeks.

Result

Contour was improved, with patch appearance gone. Almost 95% of the aesthetic subunit of the lower lip was restored, with good labial competence, no drooling, no bib, and improved profile. The intraoral lining was restored, the patchwork effect of the patient’s scarred lip was replaced with a smooth surface to the lower lip and chin subunit almost to its entirely, and bulk was brought into the area of a chin to restore aesthetic form. A labiomental sulcus was made through the forearm flap (Figure 26).

Intraoral contraction is a known complication of free flap reconstruction for complex mandibular de- fects [8]. Restoration of intraoral lining may be addressed with skin grafts, local flaps, or another free flap [8]. As the patient’s intraoral lining was already heavily scarred, it was not felt to be an adequate recipient site for a skin graft. Local tissue options were limited as a result of the severity of his initial blast injury and his subsequent operations. The deficient intraoral lining was replaced by an extraoral-to-intraoral flap, turned over through a full-thickness incision along the border of the lower-lip vermillion and skin. This design placed scars along the subunit borders and used the patchy lower-lip skin as the replacement for the scarred lower-lip mucosa. The preserved motor function to the lower-lip vermillion was surprising and helped keep the sulcus height correct. Several delay procedures were necessary to ensure the survival of the turnover flap. At the time of inset, a second radial forearm flap was used to resurface the lower lip and chin aesthetic subunit al- most to its entirety and provided bulk for subsequent contouring of the chin. A labiomental sulcus was created through the second forearm flap as previously described.

This case demonstrates that creative use of local tissue can change seemingly unsolvable problems into significant improvements. Multiple delays may be nec- essary to safely transpose scarred tissue as a reliable reconstructive flap. In addition to restoration of the patient’s deficient gingivo-buccal sulcus, the resurfacing of the lower lip and chin subunit with unscarred skin and the creation of a labiomental sulcus as well as a chin pad improved his aesthetic outcome dramatically. Only by critically analyzing each subunit is an optimal aesthetic outcome realized.

Summary

Each case in this group represents a certain aesthetic reconstructive dilemma. Methods previously described, or novel, were tailored to each patient’s unique de- formities. The authors hope these cases will give im- petus to surgeons to try creative approaches when treating challenging soft tissue deformities of the lower face.