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Transoral Cross-Lip ( Abb é -Estlander ) Flap as a Viable and Effective Reconstructive Option in Middle Lower Lip Defect Reconstruction

View Article: PubMed Central - PubMed

ABSTRACT

The Abbé-Estlander flap surgery is a cross-lip procedure that is valuable in repairing a defect on the lower lip using a full-thickness flap, consisting of the skin, muscle and mucosa, from the upper lip. As usefulness and practicality of the flap in reconstruction of lower lip surgical defects in Asian ethnicity have not been documented, the authors present a case of successful lower lip reconstruction with a staged, Abbé-Estlander lip switching flap with commissuroplasty as an illustrative example. A 71-year-old male has presented with an ulcerating lip nodule in the middle one third of the lower lip, measuring about 1.5×2 cm across its long and short axes. Wide excision of the tumor was followed by delineation of the triangular Abbé-Estlander flap from the upper lip, in which the medial hinge point of the base was chosen as the pedicle. Then, the flap elevation was carried out from the lateral commissure and then was transferred into the lower lip defect. Three weeks later, commissuroplasty was performed to correct the rounding at the new commissure. The patient is currently performing his daily activities with no apparent compromise in orbicularis oris strength or oral continence. Given the size of the primary defect and the flap-to-defect ratio of size, the degree of microstomia was acceptable. Even with other myriad of reconstructive options at surgeons' disposal, the Abbé-Estlander lip-switching flap is a reliable, and less morbid method of lower lip reconstruction for Asian surgical candidates. The authors illustrate an exemplary case in which a relatively large lower lip defect was successfully repaired using an upper lip flap of a significantly smaller size in an Asian subject of advanced age, without any remarkable long term sequelae which have traditionally been associated with the trans-oral lip switching flap technique.

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Related in: MedlinePlus

Histopathological findings of the excised tumor at (A) low magnification (H&E, ×40) shows poorly-differentiated squamous cell carcinoma showing diffuse invasion. Superficial portion of the underlying skeletal muscle is also involved (inset: ×200). Nuclear pleomorphism and intratumoral nercrosis are evident in (B); H&E, ×200.
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Figure 3: Histopathological findings of the excised tumor at (A) low magnification (H&E, ×40) shows poorly-differentiated squamous cell carcinoma showing diffuse invasion. Superficial portion of the underlying skeletal muscle is also involved (inset: ×200). Nuclear pleomorphism and intratumoral nercrosis are evident in (B); H&E, ×200.

Mentions: A 71-year-old Korean male, a farmer by profession, has presented with an elliptical, friable, ulcerating lip nodule in the middle one third of the lower lip, measuring 1.5×2 cm across its long and short axes, respectively. The tumor caused a significant edema and distortion of the vermilion border (Fig. 1A). A 4-mm punch biopsy was taken and the pathology report showed a poorly-differentiated squamous cell carcinoma with deep invasion down to the muscle. Preoperative workup included head and neck computed tomography, which revealed no infiltration of the tumor into the adjacent tissue and no significant enlargement of local lymph nodes. Because the projected extent of tumor extirpation, amount of blood loss, and the risk of wound infection, the patient was admitted the day before operation and prophylactic intravenous antibiotics was administered. On the operating table, a wedge-excision of the tumor with a generous tumor-free margin created a triangular defect measuring about 5.1 cm at its base and 4.8 cm and 4 cm at its vertical limbs (Fig. 1B). Delineation of a right-triangular Abbé-Estlander flap from the upper lip, measuring about 1.5×1.5×2.3 cm was done and the flap was to be pedicled medially. Flap elevation was then carried out from the lateral commissure, and then the pedicled flap was pivoted 180 degrees and interposed into the lower lip defect. The flap was sutured into place with approximation of the two edges of orbicularis oris muscle using a 5-0 absorbable, followed by the closure of the mucosal side with a 5-0 vicryl. Skin suture was done with a 6-0 nonabsorbable; the donor site was closed primarily with the same suture material (Fig. 2A). The pathology report provided the final diagnosis of poorly differentiated squamous cell carcinoma of the lip, with the carcinomatous cells penetrating down to muscle (Level V invasion). Involvement of peripheral/deep margins, lympho-vasculature, and perineurium was not seen (Fig. 3). For the following three days after the first stage, the patient was allowed liquid diet only, and after tolerability was affirmed, it was gradually replaced with increasingly more solid types of diet. Three weeks later, division of the pedicle “hinge” point was performed and the flap was allowed to be set in place. He has hence been followed up with outpatient visit to the clinic every four weeks. The patient reported that he hardly experienced weakening of orbicularis oris muscle strength or oral incontinence of solid or liquid content. The degree of microstomia, which is considered more or less inevitable with the lip switching flap procedures, was considered acceptable, given especially the size of the primary defect (Fig. 2B).


Transoral Cross-Lip ( Abb é -Estlander ) Flap as a Viable and Effective Reconstructive Option in Middle Lower Lip Defect Reconstruction
Histopathological findings of the excised tumor at (A) low magnification (H&E, ×40) shows poorly-differentiated squamous cell carcinoma showing diffuse invasion. Superficial portion of the underlying skeletal muscle is also involved (inset: ×200). Nuclear pleomorphism and intratumoral nercrosis are evident in (B); H&E, ×200.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5383748&req=5

Figure 3: Histopathological findings of the excised tumor at (A) low magnification (H&E, ×40) shows poorly-differentiated squamous cell carcinoma showing diffuse invasion. Superficial portion of the underlying skeletal muscle is also involved (inset: ×200). Nuclear pleomorphism and intratumoral nercrosis are evident in (B); H&E, ×200.
Mentions: A 71-year-old Korean male, a farmer by profession, has presented with an elliptical, friable, ulcerating lip nodule in the middle one third of the lower lip, measuring 1.5×2 cm across its long and short axes, respectively. The tumor caused a significant edema and distortion of the vermilion border (Fig. 1A). A 4-mm punch biopsy was taken and the pathology report showed a poorly-differentiated squamous cell carcinoma with deep invasion down to the muscle. Preoperative workup included head and neck computed tomography, which revealed no infiltration of the tumor into the adjacent tissue and no significant enlargement of local lymph nodes. Because the projected extent of tumor extirpation, amount of blood loss, and the risk of wound infection, the patient was admitted the day before operation and prophylactic intravenous antibiotics was administered. On the operating table, a wedge-excision of the tumor with a generous tumor-free margin created a triangular defect measuring about 5.1 cm at its base and 4.8 cm and 4 cm at its vertical limbs (Fig. 1B). Delineation of a right-triangular Abbé-Estlander flap from the upper lip, measuring about 1.5×1.5×2.3 cm was done and the flap was to be pedicled medially. Flap elevation was then carried out from the lateral commissure, and then the pedicled flap was pivoted 180 degrees and interposed into the lower lip defect. The flap was sutured into place with approximation of the two edges of orbicularis oris muscle using a 5-0 absorbable, followed by the closure of the mucosal side with a 5-0 vicryl. Skin suture was done with a 6-0 nonabsorbable; the donor site was closed primarily with the same suture material (Fig. 2A). The pathology report provided the final diagnosis of poorly differentiated squamous cell carcinoma of the lip, with the carcinomatous cells penetrating down to muscle (Level V invasion). Involvement of peripheral/deep margins, lympho-vasculature, and perineurium was not seen (Fig. 3). For the following three days after the first stage, the patient was allowed liquid diet only, and after tolerability was affirmed, it was gradually replaced with increasingly more solid types of diet. Three weeks later, division of the pedicle “hinge” point was performed and the flap was allowed to be set in place. He has hence been followed up with outpatient visit to the clinic every four weeks. The patient reported that he hardly experienced weakening of orbicularis oris muscle strength or oral incontinence of solid or liquid content. The degree of microstomia, which is considered more or less inevitable with the lip switching flap procedures, was considered acceptable, given especially the size of the primary defect (Fig. 2B).

View Article: PubMed Central - PubMed

ABSTRACT

The Abbé-Estlander flap surgery is a cross-lip procedure that is valuable in repairing a defect on the lower lip using a full-thickness flap, consisting of the skin, muscle and mucosa, from the upper lip. As usefulness and practicality of the flap in reconstruction of lower lip surgical defects in Asian ethnicity have not been documented, the authors present a case of successful lower lip reconstruction with a staged, Abbé-Estlander lip switching flap with commissuroplasty as an illustrative example. A 71-year-old male has presented with an ulcerating lip nodule in the middle one third of the lower lip, measuring about 1.5×2 cm across its long and short axes. Wide excision of the tumor was followed by delineation of the triangular Abbé-Estlander flap from the upper lip, in which the medial hinge point of the base was chosen as the pedicle. Then, the flap elevation was carried out from the lateral commissure and then was transferred into the lower lip defect. Three weeks later, commissuroplasty was performed to correct the rounding at the new commissure. The patient is currently performing his daily activities with no apparent compromise in orbicularis oris strength or oral continence. Given the size of the primary defect and the flap-to-defect ratio of size, the degree of microstomia was acceptable. Even with other myriad of reconstructive options at surgeons' disposal, the Abbé-Estlander lip-switching flap is a reliable, and less morbid method of lower lip reconstruction for Asian surgical candidates. The authors illustrate an exemplary case in which a relatively large lower lip defect was successfully repaired using an upper lip flap of a significantly smaller size in an Asian subject of advanced age, without any remarkable long term sequelae which have traditionally been associated with the trans-oral lip switching flap technique.

No MeSH data available.


Related in: MedlinePlus