Experience of Island Nasolabial Flap for Patients with Oral Cavity Cancer

Abstract

Aim

To find out the utility of the island nasolabial flap in patients with oral cavity malignancy.

Materials and methods

This was an observational study conducted at a super-specialty hospital in Maharashtra from October 2019 to December 2021. Patients with oral malignancy planned for island nasolabial flaps were only considered.

Results

A total of 20 patients were operated on, out of which 16 were males and 4 were females. All the patients were followed up for a minimum period of 6 months. The hospital’s online reporting system is used for the data collection including the post-operative assessment. Out of the 20 patients, 10 patients were suffering from tongue carcinoma, 6 patients from buccal mucosal carcinoma, two from hard palate carcinoma and one patient each from the floor of the mouth and lip carcinoma. The mean age of the series was 52.3 years, the average duration of the surgery is 169.4 min and the average hospital stay in the series was 4.35 days. The Ryle’s tube was removed on an average of 4.35 days. No flap-related complications were noted during the series, and healing of the donor site was uneventful. The functional outcomes after the reconstruction are acceptable in all the cases except in the lip reconstruction patient where there was post-operative drooling.

Conclusion

The island nasolabial flap is relatively easy to harvest and less time-consuming. The other advantages include the post-operative surgical scar falls along the nasolabial fold, long pedicle length with preservation of the facial pedicle for future microvascular use, early transfer to the oral feed from the nasogastric feed, and early de-cannulation. In our small study, we observed that the island nasolabial flap is a very useful flap for the small to moderate-sized defects of the oral cavity. We feel, one of the disadvantages of this flap is that it is not an ideal flap for lip reconstruction.

Introduction

For the last 2000 years, pedicle flaps are in use in the field of reconstruction. But only in 1898, the first case of single-stage island pedicle flap for lower eyelid reconstruction was reported by Monks. The term island flap was used by Essar, a Dutch surgeon in 1917 during the time of the First World War. [1–3]. When the normal pedicle flap is detached from all sides of the surrounding tissue and the only attachment with the underlying tissue is via the vascular pedicle, it is then termed as a pedicle island flap.

The pedicle island flap has two characteristics, firstly it is detached from all the sides with meticulous dissection and secondly, the only connection with the body is via the vascular pedicle [4]. Nasolabial flap is one of the widely used flaps for small to moderate-sized defects of the oral cavity and the face. In 600 BC, Sushruta described a flap similar to today’s Nasolabial flap.

There is an excess of skin at the nasolabial fold which can be used for various orofacial reconstructions, especially the tongue, hard palate, buccal mucosa, and lip defects [5]. Adequate reach can be an issue at times for the conventional nasolabial flap. The islanded nasolabial flap can address this issue with an acceptable functional and cosmetic outcome. With a long pedicle, the reach of the flap is increased significantly, and also the safety of the flap is not compromised. The flap dissection may be carried out to the origin of the flap’s pedicle from the facial vessels and then the flap can be brought inside the oral cavity through the floor of the mouth. Also, the harvesting of the flap doesn’t hamper the nodal clearance in patients with head and neck cancer. As the microvascular free tissue transfer needs resources and expertise, it is not always possible to use free flaps in all the cases in high-volume centres, especially in the govt setup. In these scenarios, these local island flaps play a major role in reconstruction.

Materials and Methods

This study was conducted at a cancer centre in Maharashtra from October 2019 to December 2021. The island nasolabial flap was used to reconstruct the defects that occurred after cancer resection. The site and size of the defect dictate the planning of the surgery. The complications associated with the surgery are assessed along with the duration of the hospital stay. A total of 20 patients were operated on, out of which 16 were males and 4 were females. All the patients were followed up for a minimum period of 6 months. The hospital’s online reporting system is used for the data collection including the post-operative assessment. SPSS version 22 was used for the data keeping and for few basic statistical analyses. Statistically significant P value was kept at 0.05.

A Brief Description of the Flap and Its Harvesting Technique

The nasolabial muscles and the skin derive their blood supply from the subdermal plexus from the feeder’s vessels and the branches of the facial artery. The main branches of the facial artery supplying this region are the superior and the inferior labial artery, the alar and lateral nasal arteries. One can locate the facial artery in the connective tissues at the oral commissure, and afterward trace the artery along the upper lip (upper border), nasal ala, and medial canthus of the corresponding eye. The maximum density of perforators supplying the flap can be located at the inferior two-thirds of the nasolabial groove. In some places, the facial artery is deep to the muscles (Platysma, risorius, zygomaticus major and minor) and in some places, it is superficial to the muscles (buccinator, levator anguli oris). As the artery is deep into most of the muscles, while harvesting it is harvested as a musculocutaneous flap.

Surgical Technique

Centering the flap at the nasolabial groove, a fusiform flap is planned with an average dimension of 6 cm x 2.5 cm (length: breadth). (Fig. 1) In patients with redundant skin laxity, breadth can be taken up to 5 cm. The superior extent of the incision is just below the medial canthus and the lower extent depends on the location of the defect and the reach of the flap. The incisions are made according to the surface marking (according to the size of the defect) and harvesting of the flap is done in a direction superior to inferior. The plane of dissection is below the location of the facial musculature, facial artery, and facial vein. The parotid duct needs to be preserved. The superior labial artery may require ligation. The whole flap is islanded, and dissection of the pedicle is done till the neck to the origin from the external carotid artery and the internal jugular vein. At times, subcutaneous tunnelling from the inferior border of the flap to the inferior border of the mandible may facilitate the easy delivery of the flap to the neck. For easy delivery of the flap inside the oral cavity, tunnelling through the buccal space or the floor of the mouth muscles (mylohyoid muscle) was needed. Attention should be paid so that there is no compression of the pedicle. We can plan lateral skin advancement to counter the distortion of the lower eyelids in case of flaps with larger widths for primary closure. The width of the flap depends on the requirement for the defect as well as the elasticity of the facial skin. Primary closure of the donor site is must for all the cases.

Fig. 1.

Marking of the island nasolabial flap; planned for tongue reconstruction

The Results and Observations

In our series, the average mean age is 52.3 years. The age of the youngest patient is 35 years and the oldest is 72 years. All 20 patients, were suffering from squamous cell carcinoma of the oral cavity region. The location of the tumour are tongue 10 cases, buccal mucosa 6 cases, floor of the mouth 1 case, lip 1 case and hard palate 2 cases. The average duration of surgery was about 169.4 min for the carcinoma tongue patients including the excision and reconstruction. Similarly, for the buccal mucosa, the floor of the mouth, lip, and hard palate patients, the average time durations are 131.3 min, 150 min, 135 min, and 137.5 min respectively. The vascularity of the flap is very good and there was no incidence of any flap necrosis(partial/total). Hair growth is not an issue in most of the cases, as the flap was harvested from the non-hair bearing areas of the nasolabial fold. For large defects requiring bigger sized flap, there is possibility of taking the flap from the hair bearing areas but that can be managed post-operatively. All the wounds were closed primarily and there was no incidence of any suture dehiscence or scar-related issues during the follow-up period. The average hospital stay was 4.35 days. Ryle’s tube was removed on an average of 4.35 postoperative days. A tracheostomy tube was needed for 5 patients and on average tube was removed on 3.8 days. Except for the lip reconstruction case, other patients have an acceptable cosmetic outcome. The functional outcomes after the reconstruction are acceptable in all the cases except in the lip reconstruction patient where there was post-operative drooling.

Discussion

Sushruta, was the first to introduce the use of the nasolabial flap in 600 BC. It is one of the commonest local flaps used for small to medium-sized defects of the head and neck region even nowadays. Many surgeons in past have modified it according to their needs and so the flap underwent many transitions since the time of its inception [6]. Initially only conventional nasolabial flaps were used for the reconstruction of oral cavity defects but this flap had one major drawback i.e., two staged procedures. J.F.S Esser was a Dutch plastic surgeon, who performed more than ten thousand difficult reconstructions during the era of the first world war and he was the person who first implemented the concept of the island flaps [7]. In 1966, Wallace gave the idea of de-epithelization of the flap [8]. Lazaridis Et all published their data on island nasolabial flaps of 9 patients in 2008. In their paper, they mentioned that flap survival is independent of the base of the pedicle (either superiorly or inferiorly based) and there was no incidence of any flap infection, dehiscence, or necrosis in their series. According to them, these flaps are useful for small and intermediate-size defects of the buccal mucosa [9]. Sharma et al. in 2021 published their data on island nasolabial flap for tongue reconstruction based on the retrospective analysis of 11 tongue cancer patients from January 2019 to August 2019. They opined that, this flap should be considered as a local flap of choice for tongue reconstruction due to its excellent reach even to the contralateral side and base of the tongue along with good post-operative tongue functionality, they even compared these outcomes with the free flap [10].

Lazaridou Et all in 2016 described that de-epithelisation of the island flap helps in one-stage closure of the defect but there is the possibility of ischaemic complications if the pedicle is excessively stressed. Almost all the complications of their study were reported from the island nasolabial flap group. They reported 11 flap-related complications (22%), and three total flap necrosis (6%), all of whom had island flaps [11]. Monarca et al. concluded that in the case of all nose reconstruction, island flaps avoid distortion of the nose tip, there is the better recovery of the alar groove and fewer chances of contracture of the reconstructed area and all these help in the prevention of the collapse of the ala and nose during inspiration [12].

In a summary, we find that island nasolabial flap is a very useful one for small to medium-sized defects, the mean operative time is considerably less, donor and the recipient site is at the same region making it convenient for the surgeon and the scrub nurse. Primary closure was possible at the donor site and the final scar falls along the natural skin creases giving a better aesthetic appearance and patient compliance. The facial pedicle is preserved in the primary surgery and hence can be readily used for future microvascular procedures. We could transfer the patient from nasogastric to oral feed in a very short time frame which further strengthens the versatility of island nasolabial flaps. Quality of life and recovery is greatly enhanced by early decannulation (Fig. 2, 3, 4, 5). The functional outcomes after the reconstruction are acceptable in all the cases except in the lip reconstruction patient where there was post-operative drooling (Fig. 6). Hair growth can be an issue in flaps with larger dimensions, but that can be managed post-operatively.

Fig. 2.

Tongue reconstruction with island nasolabial flap (6 month follow up patient)

Fig. 3.

Reconstruction of the buccal mucosa with the island nasolabial flap.( one week follow up patient)

Fig. 4.

Inappropriate lip reconstruction with island nasolabial flap. (Post operative drooling present)

Fig. 5.

Palate reconstruction with island nasolabial flap; hair growth seen at the flap.(6 Month follow up patient)

Fig. 6.

Primary closure of the wound; scar lies along the nasolabial groove.(intra-op)

Conclusion

The island nasolabial flap is relatively easy to harvest and less time-consuming. The other advantages include the post-operative surgical scar falls along the nasolabial fold, long pedicle length with preservation of the facial pedicle for future microvascular use, early transfer to the oral feed from the nasogastric feed, and early de-cannulation. In our small study, we observed that the island nasolabial flap is a very useful flap for the small to moderate-sized defects of the oral cavity. We feel, one of the disadvantages of this flap is that it is not an ideal flap for lip reconstruction.

Declarations

Conflict of interest

The authors declare that there is no conflict of interest.

Any Financial Support and Sponsorship

Nil.