J Oral Maxillofac Surg 69:e256-e259, 2011
Esthetic and Safe Lower Lip Reconstruction of an Asymmetric Defect Due to Cancer Resection: A Modified Webster Method Combined With a Nasolabial Flap Tomohiro Minagawa, MD,* Taku Maeda, MD,† and Ryuta Shioya, MD‡ The lower lip is a common site prone to squamous cell carcinoma, which arises in the facial region. Although numerous techniques for reconstructing the excised lip region have been well-documented,1 refinements to reconstructive techniques are continuously being investigated.2-4 In 1960 Webster et al5 reported on a reconstructive procedure for the lower lip using cheek and lip advancement flaps with esthetic and functional results (Fig 1). Unlike post-traumatic reconstructions, laterality of the primary tumor and regional lymph node metastases should be taken into consideration when using the surrounding local tissue to avoid unpredictable locoregional recurrences. However, few reports have addressed the relationship between laterality of the defect and reconstructive method. We present a novel method, originating from the Webster method that is limited to treating asymmetric full-thickness defects that are occasionally encountered in the clinical setting.
nasolabial fold parallel to the mentolabial fold (Fig 2A). The buccal mucosa of the unaffected side was also incised down to the buccinator muscle. In addition, the intraoral labial mucosa was incised along the gingivolabial groove, starting at the edge of the defect and ending at the first premolar (Fig 2B). A flap (designated A-flap) was elevated by subperiosteal dissection of the mandible at the inferior margin of the flap. Next, blunt dissection of the orbicularis oris muscle was performed at the lateral edge of the A-flap to mobilize it toward the defect (Fig 2C). A semilunar nasolabial flap (designated C-flap) was also elevated from the contralateral side of the defect with a subcutaneous pedicle (Fig 2C). This was followed by lateral retraction of the remaining flap (designated B-flap), which was replaced with the C-flap (Fig 2D). In the original Webster method, this nasolabial area was discarded5 (Fig 1); however, our procedure provided a Z-plasty effect, which prevented medial shift of the oral commissure. In addition, there was no need to identify and isolate the motor nerve of muscles located in each flap. All flaps were transferred and sutured in 3 layers from the oral mucosa. Lastly, the defect of the vermilion was resurfaced with a hinged buccal mucosa (Fig 2D).
Operative Technique An initial skin incision was made along the mentolabial fold down to the mentalis muscles. Another incision was made between the vermilion at 3 mm medial to the unaffected oral commissure and the
Case Report
*Department of Plastic and Reconstructive Surgery, AsahikawaKosei General Hospital, Asahikawa City, Hokkaido, Japan. †Department of Plastic and Reconstructive Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan. ‡Department of Plastic and Reconstructive Surgery, AsahikawaKosei General Hospital, Asahikawa City, Hokkaido, Japan. Address correspondence and reprint requests to Dr Minagawa: Department of Plastic and Reconstructive Surgery, Asahikawa Kosei General Hospital, 1 Jo-Dohri 24 Chome 111, Asahikawa, Hokkaido, Japan; e-mail:
[email protected]
The representative case was a 69-year-old man who presented with an ulcerative nodule measuring 20 ⫻ 9 mm on the vermilion of the lower lip. Incisional biopsy was carried out with the patient under local anesthesia; the histologic diagnosis was moderately differentiated squamous cell carcinoma. A sentinel lymph node biopsy, wide excision of the primary tumor, and immediate reconstruction of the lower lip defect were then performed with the patient under general anesthesia. The tumor was excised with a 10-mm surgical margin (Fig 3A). The resulting defect involved two thirds of the lower lip including the ipsilateral oral commissure. The defect was immediately reconstructed with the modified Webster method (Fig 3B-D). All flaps survived without congestion, and the postoperative clinical course
© 2011 American Association of Oral and Maxillofacial Surgeons
0278-2391/11/6906-0091$36.00/0 doi:10.1016/j.joms.2011.01.007
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FIGURE 1. Schema of Webster method. a, Triangle areas lateral to the nasolabial folds (2 asterisks) and in the labiomental grooves (1 asterisk) are discarded for mesial advancement. b, Horizontal scarring between the oral commissure and nasolabial fold (arrowheads) can show unnatural appearance. Minagawa, Maeda, and Shioya. Lower Lip Reconstruction. J Oral Maxillofac Surg 2011.
was uneventful. Histopathologic examination showed complete clearance of the primary tumor despite muscular invasion; metastasis was detected in a sentinel lymph node in the submental region. According to the histologic diagnosis,
adjuvant radiotherapy of the neck was initiated on postoperative day 9. No sign of locoregional recurrence or metastasis was observed during 12 months of follow-up. Adequate opening of the mouth (incisor-to-incisor distance of
FIGURE 2. Schema of modified Webster method. A, A, B, and C denote the flap design. The dotted circle shows the resection of the carcinoma. B, Intraoral incisions to generate the A-flap. M indicates a mucosal flap for neo-vermilion. C, Elevation of C-flap subcutaneously. The partially transected orbicularis oris and the preserved buccinator muscle within the A-flap should be noted. D, Final appearance of reconstruction. Minagawa, Maeda, and Shioya. Lower Lip Reconstruction. J Oral Maxillofac Surg 2011.
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FIGURE 3. A case involving T4N1M0 squamous cell carcinoma in a 69-year-old man. A, Design of wide excision with a 10-mm margin. B, Intraoperative view showing defect and flap design. C, Elevation of the 3 flaps. D, Final appearance of modified Webster method. E, F, G, Postoperative views at 12 months’ follow-up. The adequate opening of the mouth (E), proper sphincter function (F), and inconspicuous scarring (G) should be noted. Minagawa, Maeda, and Shioya. Lower Lip Reconstruction. J Oral Maxillofac Surg 2011.
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MINAGAWA, MAEDA, AND SHIOYA 40 mm) was achieved, and sphincter function was restored (Figs 3E,F). Moreover, satisfactory esthetic results were achieved, with only inconspicuous scarring along the facial units (Fig 3G).
Discussion The modified Webster technique showed satisfactory results both functionally and esthetically. A number of modifications were made to the original technique (Fig 2). First, all flaps were designed for the side opposite the carcinoma, not bilaterally. Some reconstructive methods require isolation of the motor nerve within flaps near facial vessels6,7; however, the submandibular region is susceptible to lymph node metastases. Thus dissection in this area carries the risk of disseminating lymph node metastases. Second, cheek skin lateral to the nasolabial fold is preserved as a local flap, although this area is discarded as a Burow triangle in the original method (Fig 1). A nasolabial flap provides not only suitable skin for a white lip with excellent color and texture match but also a Z-plasty effect to prevent a medial shift of the oral commissure, which can cause microstomia. Third, focus was placed on esthetic refinements. That is, the unaffected oral commissure was preserved, and unnatural horizontal scarring between the oral commissure and nasolabial groove, which was frequently observed with the original method, was prevented. On the other hand, the modified Webster method is not appropriate for large symmetric defects. Further-
more, this unilateral method is not indicated for the entire lower lip reconstruction. In our 2 experiences, it is limited to treating defects that comprise approximately 70% of the maximum defect. The modified Webster method can be applied to asymmetric defects involving approximately two thirds of the lower lip, regardless of oral commissure defects, without dissections between the primary tumor and ipsilateral submandibular region. Our results support the utility of the modified Webster method as an alternative for reconstruction of a partially defective lower lip.
References 1. Zide BM: Lower lip reconstruction, in McCarthy JG (ed): Plastic Surgery. Volume 3. Philadelphia, Saunders, 1990, pp 2012-2027 2. Roldán JC, Teschke M, Fritzer E, et al: Reconstruction of the lower lip: Rationale to preserve the aesthetic units of the face. Plast Reconstr Surg 120:1231, 2007 3. Yamauchi M, Yotsuyanagi T, Ezoe K, et al: Estlander flap combined with an extended upper lip flap technique for large defects of lower lip with oral commissure. J Plast Reconstr Aesthet Surg 62:997, 2009 4. Weschselberger G, Gurunluoglu R, Bauer T, et al: Functional lower lip reconstruction with bilateral cheek advancement flaps: Revisitation of Webster method with a minor modification in the technique. Aesthetic Plast Surg 26:423, 2002 5. Webster RC, Coffey RJ, Kelleher RE: Total and partial reconstruction of the lower lip with innervated muscle-bearing flaps. Plast Reconstr Surg 25:360, 1960 6. Karapandzic M: Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 27:93, 1974 7. Nakajima T, Yoshimura Y, Kami T: Reconstruction of the lower lip with a fan-shaped flap based on the facial artery. Br J Plast Surg 37:52, 1984
