Subcutaneous Randomized Nasolabial Flap: Our Experience

Abstract

Nasolabial flaps are one of the oldest methods of reconstruction. This study aims to observe the viability of a random-pattern subcutaneous nasolabial flap. Inpatients of carcinoma of oral cavity and nose undergoing excision with primary reconstruction from January 2014 to December 2019 were observed and followed-up. Their data including site of primary and post-operative complication was recorded. A total of 38 patients underwent reconstruction using nasolabial flap. Most cases were of buccal mucosa carcinoma (68.4%). Facial vessels were ligated in all except 7 cases and, only 1 (2.6%) showed total, and 3 (7.9%) showed partial flap necrosis. A subcutaneous nasolabial flap is simple, viable and easy to harvest. It is a random-pattern flap therefore; facial vessel preservation may not be a compulsion. Flap raised subcutaneously is thinner and thus inset is easy and bulk associated discomfort is avoided.

Introduction

Historically, cheek flap and forehead flap were the first flaps described for head and neck reconstruction. The nasolabial flap was described for nasal reconstruction by Sushtruta in 600BC, and thus plastic surgery was born about 2000 years ago in India. Ever since, the nasolabial flaps have been a workhorse for face and oral cavity reconstructions. The relative ease of harbouring and ability to carry out this procedure under local anaesthesia along with the benefit of relatively minimal scar makes it one of the most widely used flaps.

The nasolabial region is complex in its anatomy. The crease extending from lateral alar rim to the corner of mouth forms the nasolabial sulcus. Muscles lying beneath the skin and subcutaneous tissue of this region are platysma, risorius, zygomaticus major and minor, levator labii superioris and levator labii alaeque nasi. Deep to this and superficial to the buccinator runs the facial artery which is the major vessel supplying this region. It gives perforating branches to overlying skin and subcutaneous tissue.

The facial artery is a branch of external carotid and runs a sinous course. It appears on the face at the antero-inferior border of masseter by turning around the lower border of mandible and then runs antero-superiorly up to 1.5 cm from the angle of mouth and then vertically to end near the medial angle of eye [1].

The subdermal vascular plexus formed by facial, angular, transverse cervical and infraorbital vessels provides the blood supply to nasolabial skin and muscles.

Many authors are of the opinion that the nasolabial flap has an axial blood supply. They can be superiorly, inferiorly, medially or centrally based flap. Inferiorly based flaps are supplied by the facial artery and superiorly based flaps are supplied by the superficial temporal artery (through its transverse facial branch) and the infraorbital artery. Medially based flap is nourished by lateral nasal branch of facial artery. The flap is commonly designed lateral to nasolabial fold with the medial limit of flap being 2–3 mm lateral to this fold. The superior limit of the flap is kept inferior to the medial canthus while the inferior limit depends on the nature of defect.

The study showed that the flap has a random blood supply from the premaxilla as facial artery was ligated in 83% cases yet the flap survived in most cases. It is used in a variety of situations including reconstruction of the lower eyelid and small defects of the nose, lips and oral cavity. In cancer treatment its major role is for reconstruction of the buccal mucosal defects, floor of the mouth, palate and ala of the nose. In our institution we have used this flap for a variety of oral and alar defects after cancer excision and have found it to be a very versatile and dependable flap. This paper presents a series of diverse cases where random pattern subcutaneous nasolabial flaps were used (Figs. 1, 2).

Fig. 1.

Clinical Photograph of Right side subcutaneous nasolabial flap

Fig. 2.

Clinical photograph of a bilateral nasolabial Flap

Materials and Methods

The study was conducted in the Department of Otorhinolaryngology and Head and Neck Surgery, Dr. S. N. Medical College and associated group of hospitals, Jodhpur. Biopsy proved cases of carcinoma of nose and oral cavity undergoing wide excision with nasolabial flap reconstruction within a period of 6 years from January 2014 to December 2019, were observed and followed up for the method of flap harvest, inset and post-operative result along with complications.

• Study Design It is a descriptive retrospective observational type of study.

• Study Period 6 years.

• Study Area Department of Otorhinolaryngology and Head and Neck Surgery, M.D.M. Hospital, Dr. S.N. Medical College, Jodhpur, Rajasthan, India.

Inclusion Criteria

1. All patients with biopsy proved case of carcinoma of oral cavity and nose, and who underwent surgery with flap reconstruction.

2. All patients who gave positive written informed consent.

Exclusion Criteria

1. Patients who were given radiotherapy as the primary treatment modality.

2. Cases in which defect was covered with primary closure, split thickness skin graft or any other flap.

3. Patients unfit for general anaesthesia.

Methodology

We retrospectively observed and followed-up 38 cases of carcinoma of oral cavity and nose who had undergone excision and reconstruction using a nasolabial flap between January 2014 and December 2019. The data was obtained from hospital records. The site of primary, age and sex distribution was studied. Operative notes were studied to identify the method of flap harvest and inset. It was observed that in majority of our cases of oral cancers we have used an inferiorly based nasolabial flap. Skin incision was made till the level of subcutaneous tissue in a fusiform pattern. Facial artery lies deep to muscles of expression and was tied during neck dissection in most of the cases. The flap was elevated in superior to inferior direction subcutaneously. The subcutaneous flap based on a random-pattern blood supply so developed was tunnelled through the buccal space to fill the intraoral defect. And if the angle of mouth was included in the excised primary, then the flap was rotated and inserted into the defect site.

For alar defects, nasolabial flap was based on angular branch of facial artery. Plane of dissection was kept between subcutaneous tissue and the muscles. The flap was transposed to the defect site and sutured in layers.

These patients were followed-up for the status of the flap, post operative complications, functional outcome in terms of speech and swallowing, recurrence etc. (Fig. 3).

Fig. 3.

Clinical Photograph of a flap inset in a case of carcinoma of buccal mucosa, b persistent oro-cutaneous fistula, a post operative complication

Results and Analysis

The study included a total of 38 cases between the 20–80 years of age. Out of which, 25 (65.8%) were male patients and 13 (34.2%) were females (Tables 1, 2).

Table 1.

Age distribution (n = 38)

Age (yrs)	Male	Female	Total	Percentage
20–30	1	0	1	2.6
30–40	0	3	3	7.9
40–50	10	0	10	26.3
50–60	6	5	11	28.9
60–70	7	4	11	28.9
70–80	1	1	2	5.3

Table 2.

Gender distribution (n = 38)

Gender	Number	Percentage
Male	25	65.8
Female	13	34.2
Total	38	100

The site of the disease for which nasolabial flap was used included nose, upper and lower lip, buccal mucosa, floor of mouth and oral commissure cancers. It was observed that majority of cases were of buccal mucosa cancer (68.4%) affecting males more than females (1.9:1) of age group 50–70 years.

An inferiorly based nasolabial flap was taken for reconstruction in a total of 37 cases and superiorly based flap was raised in 1 case. The flap was tunnelled or rotated and inset into the defect site for all oral defects. Out of 38 cases, 24 patients underwent modified radical neck dissection (MRND), 6 underwent supra-omohyoid neck dissection (SOHND), 1 had bilateral neck dissection and in 7 cases neck dissection was not done. Facial vessels were ligated in all the cases undergoing neck dissection (Table 3).

Table 3.

Distribution of tumor by site (n = 38)

Site	Number of tumor	Percentage
Nose	5	13.1
Upper lip	1	2.6
Lower lip	1	2.6
Buccal mucosa	26	68.4
Floor of mouth	4	10.5
Oral commissure	1	2.6

In the early post operative period morbidity due to wound infection, hematoma formation, skin blackening was seen in 7 patients (3, 2, 2 respectively) (26.2%). 5 out of 31 patients (13.2%) complained of drooling of saliva in the early post operative period.

Total flap necrosis occurred in 1 patient (2.6%) while only 3 (7.9%) showed partial flap necrosis which later recovered. The nasolabial flap was tunnelled into the oral cavity in 30 cases. Out of these 30 cases, only 2 (6.7%) remained with persistent oro-cutaneous fistula and underwent a second stage procedure for its closure under local anaesthesia. While 2 (5.2%) suffered from whistle deformity, 5 (16.7%) patients developed trismus post-operatively.

All the patients had good and intelligible speech, were able to swallow both solids and liquids. 5 out of 38 operated cases have developed recurrence (Table 4).

Table 4.

Post-operative flap complications

Complication	Number	Percentage
Early
Hematoma	2	5.2
Occular edema	0
Erythema	3	7.9
Infection	3	7.9
Wound dehiscence	0
Seroma	0
Drooling of saliva	5	13.2
Skin blackening	2	5.2
Late
Flap necrosis	3	7.9
Total flap necrosis	1	2.6
Persistent oro-cutaneous fistula	2 (out of 30 cases)	6.7
Trismus	5 (out of 30 cases)	16.7
Whistle deformity	2	5.2

Discussion

In 1830, Dieffenbach used superiorly based nasolabial flap for reconstruction of defects of ala of nose. In 1917, Esser used inferiorly based flap for palatal fistula repair. Since then, various modification of this versatile flap has been described, ranging from conventional pedicled flap to subcutaneously pedicled flap to facial-artery island flap [2]. A modified application of the flap is described by Spear et al. and Kroll for total full-thickness defects of the alar margin [3].

In our series of 38 cases we have used a superiorly based flap in 1 case while in rest of the cases we have used an inferiorly based flap. Our indication for the flap’s use is in defects of the ala of nose, buccal mucosa, anterior commissure, lip, floor of mouth. The commonest site where we used nasolabial flap was for reconstruction following excision of buccal mucosa malignancy. We have used unilateral flaps in 34 cases and bilateral flaps in 2 cases. In the first case, bilateral flaps were used for carcinoma of lower lip left side extending up to opposite commissure. In the second case, it was used in a patient who had squamous cell carcinoma of right buccal mucosa and extensive leukoplakia on opposite buccal mucosa. Prior to using this flap we were using split thickness skin graft (STSG) for buccal mucosa defect reconstruction. However, with STSG, incidence of trismus encountered was very high. This necessitated us to revise our method of reconstruction. Hence we used nasolabial flap in 26 of 38 cases and 13.2% showed grade 2 trismus, out of which a few cases had pre-existing submucous fibrosis owing to the prevalent habit of tobacco chewing in India. It was observed that with the use of flap, post-operative mouth opening improved. This was similar to the results of Lazaridis et al. [4].

The advantages of nasolabial flap include, first and foremost, the ease with which it can be harvested, it falls within the same surgical field and can be raised under local anaesthesia. Thus, it is easy and less time consuming. It also gives a larger surface area and can be used for small to moderate sized defects. Maximum dimension of the flap as described, and abided by us in our study, was 7 × 1.5 cm [5]. Cosmetic results following the donor site closure are satisfactory and post operative mouth opening is better when compared to buccal pad of fat or skin grafts. Hair growth at the flap site could be discomforting, particularly in patients who do not undergo radiotherapy. We encountered the persistence of oro-cutaneous fistula in 20 cases, out of which in 2 cases it was troublesome and required surgical closure under local anaesthesia. This was similar to the observations of Varghese et al. [5]. In 9 cases, the fistula got stenosed post radiotherapy while remaining 18 refused for secondary closure as it was not affecting their quality of life.

Most of the authors, like Hagan and Walker [6], Cummings, in their studies have said that facial artery is the dominant blood supply of nasolabial flap. They strongly advocated including the facial artery within the flap to improve its reliability. Birt and Grus described the facial artery as entering the base of nasolabial flap but did not elaborate wether any perioral or perineural muscles were sacrificed during raising of the flap. Much later, in 2001, Varghese et al. [5], in their study of 224 cases of oral cancers reconstructed using nasolabial flap, found that facial artery ligation resulted in flap necrosis.

But, contrary to the accepted view, we are of the opinion that nasolabial flap has a random supply. We ligated facial artery in all but 7 cases and found no difference in flap viability. According to us, the blood supply for our flap was provided by subdermal plexus, and hence we feel that nasolabial flap has a random blood supply. Our inference of supply to nasolabial flap by subdermal plexus is supported by Hynes and Boyd who conducted an anatomic study in 1988 and concluded that facial artery passes below the facial musculature and need not be elevated with the flap. They performed cranial roentgenograms of the six injected nasolabial flaps which indicated that good perfusion of the smaller subcutaneous vessels (subdermal plexus) had occurred, but surprisingly these x-rays showed the axial nature of this random supply of the flap. Thus the concept of axiality of the random flap was first proposed by Hynes and Boyd [7] This is also similar to the observations of Rohrich and Conrad [3] and Rahpeyma and Khajehahmadi [8].

Telfer et al. [9] noted recurrence of intra-oral sqamous cell carcinoma at the base of a nasolabial flap in two cases. In our series, we did not encounter any such site preponderance with regard to tumor recurrence.

Conclusion

It may be concluded that nasolabial flap is a simple, viable and less time consuming option for nasal ala and oral cavity defects, not only for its good cosmetic results but also for the ease of harvesting and good functional results in terms of speech and swallowing. It varies in thickness from full-thickness type to dermis and epidermis (defatted) type. A subcutaneous pedicled nasolabial flap is one of the variant which is thinner and thus the discomfort associated with a bulky flap, like cheek biting, is avoided. It also thrives well on the random-patterned subdermal vasculature of the nasolabial skin, therefore; preservation of facial artery is not mandatory.

Funding

This research did not receive any specific Grant from funding agencies in the public, commercial, or not for profit sectors.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study. Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.