Versatility of bilateral nasolabial flap for reconstruction of subtotal lip defects in oral squamous cell carcinoma with commissural involvement: A case report and review literature

Abstract

Reconstruction of the lip is crucial to regaining essential functions, including oral competency, speech articulation, and aesthetics. Reconstruction is often challenging when commissure is involved as it affects the anatomy of both the upper and lower lip as well as the size of the oral stoma. Improper commissure reconstruction results in drooling and a reduction in mouth opening. This case highlights the versatility of the simultaneous use of a bilateral nasolabial flap for the reconstruction of subtotal lower-lip defects in cases where a tumor involves one of the commissures, providing satisfactory aesthetic and functional results.

INTRODUCTION

Oral squamous cell carcinoma involving the lip poses a challenging condition requiring a comprehensive approach to restore function, including oral competency, speech, and aesthetics.[1,2] The lower lip, in particular, plays a crucial role in the articulation of speech, deglutition maintaining oral seal and facial expression.[3,4] Reconstruction of the lip following tumor resection is, therefore, essential to maintain the patient’s quality of life and social well-being.

The key advantage of the bilateral nasolabial flap is its collateral supply from the facial artery, transverse facial artery, buccal artery, masseteric artery, and infraorbital artery, as mentioned by Herbert and Harrison,[5] and its ability to provide adequate tissue for the reconstruction of subtotal or near-total lower-lip defects, particularly when the tumor involves one of the commissures, as this case presented. The technique has been widely adopted and reported in the literature as a reliable and effective option for lip reconstruction.

Various techniques exist for lip reconstruction, each with advantages and limitations. The Webster flap preserves the commissure but may cause microstomia. The Karapandzic flap maintains nerve function but can distort anatomy. The Gillies fan flap addresses subtotal defects but may cause denervation. Combined local and regional flaps, such as nasolabial with bucket handle, can reconstruct total defects. The melo-labial flap offers a good color match but limited bulk. Lip switch flaps maintain contour but may distort the shape. Myomucosal flaps provide muscle coverage and reduce microstomia risk. Free tissue transfers suit extensive defects but require microsurgical expertise and longer operating times. Patient comorbidities may contraindicate free flap procedures.

In cases where the commissure is involved, the nasolabial flap, either unilateral or bilateral, is often considered a reliable and versatile option that can provide satisfactory results. For subtotal defects of the lower lip, local flaps, such as the nasolabial flap, have been widely used to achieve satisfactory structural and functional results.[6,7,8] When the lesion involves one of the commissures of the mouth, the nasolabial flap can be an apt surgical option[9,10] due to its proximity to the defect, reliable vascularity, and the ability to provide a good color and texture match with the surrounding tissues.[11,12]

In this case report, we present the successful management of a patient with well-differentiated squamous cell carcinoma of the lower lip, involving the right commissure, using a bilateral nasolabial flap reconstruction. It emphasizes on utility of the nasolabial flap in the reconstruction of subtotal lower-lip defects, particularly in cases where the tumor encroaches on the commissure, and discusses the functional and aesthetic outcomes achieved with this technique along with the insights on the literature review.

CASE REPORT

A 49-year-old male patient reported to the unit of oral and maxillofacial surgery, with a chief complaint of growth on the right side of the lower lip for the past 2 months [Figure 1]. The patient’s history revealed that he was asymptomatic 2 months prior when he developed a non-healing ulcer over his lower lip that increased in size over time and transformed into a deeply pigmented, solitary lesion on his right lower vermilion, which gradually increased in size. There was no history of trauma and the family history was non-contributory.

Figure 1.

Pre-operative Extraoral Picture

The patient’s habits revealed a deleterious habit of tobacco chewing for the past 20 years and was a chronic smoker for the past 10 years. The patient had a known case of chronic obstructive pulmonary disease (COPD) and long-standing hypertension (HTN) and was not currently on any medication.

On extraoral examination, an ulcero-proliferative growth with an exophytic necrotic crust measuring 2.5 cm ×1.5 cm was observed on the right vermilion border, situated near the corner of the lip, without crossing the midline. The lesion was non-tender on palpation. A solitary, firm to hard, non-tender, right level Ib lymph node was palpable.

On intraoral examination, the lesion continued on the labial mucosa and the vestibule [Figure 2], presenting as an ulcero-proliferative growth and a leukoplakic patch extending from the left first premolar to the edentulous ridge on the right side, concerning the second molar. There was bone loss associated with the grade 3 mobile anterior teeth. On palpation, the area was mildly tender with bleeding on manipulation. Further examination revealed multiple missing teeth.

Figure 2.

Pre-operative Intraoral Picture

A contrast-enhanced computed tomography (CECT) of the face and neck revealed an ill-defined, oval-shaped, non-homogenous lesion with irregular borders, associated with loss of alveolar bone and erosion of the mandibular buccal cortex from the right canine to the premolar region, along with right submandibular lymph node involvement.

A Punch biopsy followed by histopathological examination of the lesion confirmed the diagnosis of well-differentiated squamous cell carcinoma.

The patient was planned for wide local excision, followed by marginal mandibulectomy and bilateral supra-omohyoid neck dissection. Owing to preexisting comorbidities such as HTN and COPD, the reconstruction using a bilateral nasolabial flap was planned for the lip and right buccal vestibular defect under general anesthesia.

After written informed consent, the patient was explained about the procedure and potential risks and benefits. The patient was found fit for surgery in a preanesthetic checkup but was at moderate respiratory risk for surgery from the chest and TB department.

Upon shifting to the operation room, the patient was intubated nasally, after throat packing, the patient was painted and draped. Wide local excision of primary tumor and marginal mandibulectomy was performed [Figure 3]. Extended supra-omohyoid neck dissection was performed.

Figure 3.

Intra-operative Picture after wide local excision and marginal mandibulectomy

For reconstruction, the skin incisions were made at a distance equivalent to the height of the lower lip to maintain the normal height of the lip. The superior incision was placed just lateral to the nasolabial crease incising the skin, subcutaneous fat. The inner mucosal incision was made parallel to the skin incision approximately 2 cm on the left side. Meticulous dissection was done to preserve the labial arteries and buccal motor nerve. The flap was released and rotated medially. Similarly, on the right side, inferior based the nasolabial flap was raised.

The plane of dissection was deep to the subcutaneous tissue and superficial to the underlying muscles. Special attention was given to preserving the integrity of the facial vessels during the neck dissection on the right side. On the left side, the flap was rotated medially to cover the lower-lip defect after being raised to the required length. On the right side, the flap was rotated inwards to the oral cavity through a mucosal tunnel. The flaps were sutured meticulously in multiple layers from the inner mucosal layer to the outer skin with minimal tension [Figure 4]. Along with comprehensive surgical management, the focus was on reconstructing critical anatomical structures such as the vermillion border, commissure of the lip, and labial vestibule and achieving optimal functional vestibular depth, commissural integrity, and oral seal, while maintaining cosmesis.

Figure 4.

Immediate Post-operative picture

The final histopathological report confirmed a lower-lip primary lesion with node metastases to the right level Ib lymph node and pathological TNM staging pT3N1 with perineural invasion. All the margins were free of tumors. At 1 month of follow-up, the patient reported a minimal scar and normal functions such as deglutition, speech, and adequate mouth opening.

DISCUSSION

The authors reported that approximately 25%–30% of all oral cancers occur on the lip, with the lower lip being the most common site.[13] In today’s era of free flaps, the bilateral nasolabial flap is not the flap of choice for reconstruction of lower-lip defects as it is accompanied by visible scars over the face. However, in middle- and low-income countries with a tremendous burden of disease, loco-regional flaps still occupy the foreground of the reconstructive landscape.

The use of bilateral nasolabial flaps for reconstruction of facial defects due to tumors has been listed in Table 1, showing results as well as postop complications seen during follow-ups. Maillard and Landry reported the use of the nasolabial flap for lower-lip reconstruction in 1980, highlighting its advantages in terms of tissue match and preservation of lip function.[9] More recently, Sabri et al.[10] reviewed 985 cases of nasolabial flap reconstruction for maxillary and oromandibular defects, including some cases involving the lower lip, and concluded it to be a versatile and reliable technique. Gupta et al.[14] described a single-stage technique for total lower-lip reconstruction using a combination of an inferiorly based nasolabial flap and a bucket handle flap from the upper lip, demonstrating good functional and aesthetic outcomes. Similarly, Hamahata et al. reported the use of a combined Webster and Johanson method, which included the use of a nasolabial flap, for near-total lower-lip reconstruction in patients with oral cavity tumors.[15] The commissure of lip reconstruction helps in providing lip seal when the patient chews food and does not allow drooling of saliva.

Table 1.

Review of Literature

Journal	Authors	Year	Age/Sex	Tumor site	Tumor size (cm)	Defect	Flap size cm	Facial artery	Healing events	Functional deficits
Oral and maxillofacial surgery	Nikolaos[17] Lazaridis, Lambros Zouloumts, Gregory Venetis et al.:	1998	55/M	Floor of the mouth	-	-	-	-	-	-
Oral and maxillofacial surgery	Nikolaos[17] Lazaridis, Lambros Zouloumts, Gregory Venetis et al.:	1998	64/M	Floor of the mouth	-	-	-	-	-	Obstructive Sialadenitis
Oral and maxillofacial surgery	Nikolaos[17] Lazaridis, Lambros Zouloumts, Gregory Venetis et al.:	1998	65/M	Floor of the mouth	-	-	-	-	-	Dehiscence, satisfactory result
Oral and maxillofacial surgery	Nikolaos[17] Lazaridis, Lambros Zouloumts, Gregory Venetis et al.:	1998	62/M	Floor of the mouth	-	-	-	-	-	-
Oral and maxillofacial surgery	Nikolaos[17] Lazaridis, Lambros Zouloumts, Gregory Venetis et al.:	1998	72/M	Floor of the mouth	-	-	-	-	-	-
Oral and maxillofacial surgery	Nikolaos[17] Lazaridis, Lambros Zouloumts, Gregory Venetis et al.:	1998	64/M	Floor of the mouth	-	-	-	-	-	-
Oral and maxillofacial surgery	Nikolaos[17] Lazaridis, Lambros Zouloumts, Gregory Venetis et al.:	1998	65/M	Floor of the mouth	-	-	-	-	-	-
Annals of plastic surgery	Nedİm[18] Sarifakioğlu, Gücan Aslan, Ahmet Terzİoğlu et al.:	2001	68/M	left lateral side of the upper lip	-	85%	6×2.5 cm	-	-	no microstomia
The Cleft palate-craniofacial journal	A.r. erç S.[19] Yılmaz, M. Saydam et al.:	2003	65/F	-	-	-	-	-	-	-
The Journal of Craniofacial Surgery	Takaya Makiguchi,[20] Satoshi Yokoo, Hidetaka Miyazaki et al.:	2005	59/M	Lower lip	4.8×2	80%	8×5	-	-	-
Journal of Plastic and Reconstructive Surgery and Hand Surgery	Gianvittorio[21] Campus, Nicola Standoli & Carmine Alfano	2009	64/M	Lower lip	4.2	-	-	-	-	-
Maxillofacial Oral Surgery	Shakti Singh[22] Deora, Madan Nanjappa, S.V. Kumaraswamy et al.:	2010	75/M	Anterior alveolus	3×1.5 cm	25%	4×2 × m	-
The Journal of Craniofacial Surgery	Takaya[23] Makiguchi, Satoshi Yokoo, Hidetaka et al.:	2013	59/M	Lower lip	4.8×2 cm	80%	-	-	-	-
The Journal of Dermatology	Nakamura,[24] Yoshiyuki, et al.	2013	66/M	columella	2 cm	-	-	-	-	-
Medicina Oral, Patología Oral y Cirugía Bucal	Alonso-Rodríguez, [25] Estefanía, et al.	2014	77/M	Floor of the mouth	-	-	-	-	Orocutaneous fistula, hematoma	-
Canadian Journal of Plastic Surgery	Gupta, Sandipan,[26] et al.	2015	41/M	Lower lip	-	100%	5×3	Ligated	-	-
Anais Brasileiros de Dermatologia	Coutinho, Inês,[27] et al.	2015	93/M	Lower lip	3 cm	80%	-	-	-	-
Plastic and Reconstructive Surgery	Osugi, Ikuko,[28] et al.	2021	67/M	Nasal tip	1×1.2	2.6×3.2	-	-	-
Journal of the Chinese Medical Association	Tsai,[29] Chien-Sheng et al.:	2022	58 M	Lower lip	2.2×2.1	50%	5.0×2.5	Ligated	Flap tip necrosis	-
Journal of the Chinese Medical Association[27]	Tsai,[29] Chien-Sheng et al.:	2022	84 M	Lower lip	2.5×1.5	75%-100%	7.0×3.0	Ligated	-	-
Journal of the Chinese Medical Association	Tsai,[29] Chien-Sheng et al.:	2022	74 M	Lower lip	1.5×1.2	50%-75%	6.5×2.5	-	Orocutaneous fistula	-
Journal of the Chinese Medical Association	Tsai,[29] Chien-Sheng et al.:	2022	80 M	Lower lip	1.5×1.3	50-75%	6.5×2.5	-	-	-
Journal of the Chinese Medical Association	Tsai,[29] Chien-Sheng et al.:	2022	71 M	Lower lip	2.2×1.6	50-75%	6.5×2.5	-	-	-
Journal of the Chinese Medical Association	Tsai,[29] Chien-Sheng et al.:	2022	59 M	Commissure	1.4×1.4	25%	6.0×3.0	-	-	Mild trismus
Journal of the Chinese Medical Association	Tsai,[29] Chien-Sheng et al.:	2022	61 M	Commissure	1.4×1.2	25%	6.0×2.5	-	-	Mild trismus
Journal of the Chinese Medical Association	Tsai,[29] Chien-Sheng et al.:	2022	53 M	Commissure	1.5×1.3	25%	5.0×2.5	-	Wound dehiscence	Mild trismus incompetence

Compared to other reconstructive techniques, such as the Webster, Karapandzic, or Gillies flaps, the bilateral nasolabial flap approach has several advantages. These flaps can be susceptible to microstomia, trismus, and distortion of the commissure, which can be particularly problematic for patients requiring adjuvant radiotherapy. In contrast, the bilateral nasolabial flap used in the present case provided good oral competency, speech, and facial expression without any significant intraoperative or postoperative complications, as also observed by Gupta S (2012) and Hamahata A (2017).[14,15]

In the present study aesthetic results were quite satisfactory as the color and texture of the nasolabial flap blended well with the surrounding tissues, maintaining the natural appearance of the lower lip. This is an important consideration as restoring the aesthetics of the lip is crucial for the patient’s psychological and social well-being. The flap was harvested according to the vertical and horizontal dimensions of the defect, preserving the inter-commissural distance and preventing the complication of microstomia, which can lead to trismus. Collateral supply from both flaps makes it highly vascular, which contributes to the longevity of bilateral flaps, as seen in the present case. The functional movement of the lower lip is retained by depressor anguli oris and depressor labii inferioris muscles that are sutured with the flap.

Generally, the complication rate is low in these cases. In a study by Singh et al., between 2006 and 2010,[16] 26 patients with oral cancer underwent reconstruction of oral defects using nasolabial flaps, The outcome was good in all cases, except for one patient who developed recurrence and one patient who developed a orocutaneous fistula that required secondary closure. In the present study, no such complication was seen after a year of follow-up after radiotherapy. This represents an excellent survival rate for this flap.

CONCLUSION

The nasolabial flap has long been described as a workhorse in the reconstruction of facial defects for immediate reconstruction after intraoral cancer resection. Flap vascularity remained reliable even after facial artery ligation. In cases of advanced oral cavity cancer involving one of the commissures, a reliable surgical technique for subtotal repair of the lower lip is the use of bilateral nasolabial flaps.

The nasolabial flap is often considered a better option than microvascular flaps for certain types of lip reconstruction for a few key reasons:

1. Technically less demanding

2. Reliable blood supply

3. Color match texture match

4. Flap thickness comparable to lip thickness

5. Shorter operative time

6. Lack of donor site morbidity

A bilateral nasolabial flap is preferred as a salvage flap in cases of free flap failure and comorbid, financially restrained patients. It presents a reliable, convenient, low-morbidity solution that is locally accessible to tissue in close proximity to the defect. The technique is not difficult to master and is used to reconstruct defects as large as 5 cm. Flap vascularity is reliable due to the rich collateral blood supply. The donor wound closes easily and results in a well-camouflaged scar in postoperative follow-ups.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.