RECONSTRUCTION OF CONCOMITANT TOTAL LOSS OF THEUPPER AND LOWER LIPS WITH A FREE VERTICAL RECTUSABDOMINIS FLAP

NAVID JALLALI, B.Sc., M.B. Ch.B. (Hons.), M.R.C.S. (Eng.),* and

CHARLES M. MALATA, B.Sc., M.B. Ch.B., L.R.C.P. M.R.C.S., F.R.C.S. (Glasg.), F.R.C.S. (Plast.)

Total loss of both lips is fortunately rare as reconstruction of such defects poses an enormous challenge. We present a caseof concomitant loss of both lips as a result of fulminant pneumococcal septicemia, which was reconstructed with a free verticalrectus abdominis myocutantous flap due to lack of traditional donor sites. ª 2005 Wiley-Liss, Inc. Microsurgery 25:118�120,2005.

The principal aims of lip reconstruction should be torestore function, maintain sensation, and accomplish anacceptable cosmetic result. Achieving these objectives inthe reconstruction of substantial lip defects is extremelychallenging. While locoregional flaps are one therapeu-tic option,1�4 extensive tissue losses often require freetissue transfer,5�10 which have almost exclusively in-volved the use of the radial forearm free flap (RFFF)due to its versatility and pliability.5�8 Concomitant lossof the upper and lower lips is an even greater recon-structive challenge, and such defects have been recon-structed with a combination of free flaps.11 The use of afree vertical rectus abdominis flap to reconstruct thetotal loss of both lips is presented.

CASE REPORT

T.R., a 37-year old man, was admitted to theIntensive Care Unit (ICU) with fulminant pneumococ-cal septicemia. He was referred to the Plastic Surgeryteam with widespread ischemic necrosis of his extremi-ties, which resulted in the total debridement of both hisupper and lower lips (Fig. 1) as well as the distal half ofhis nose (i.e., the tip, collumella, alar-nostril, soft-tri-angle subunits, and cartilaginous septum). He alsounderwent bilateral below-elbow and below-knee guil-lotine amputations as part of the same illness.

An attempt to reconstruct the upper lip with aWebster’s perialar advancement flap was unsuccessful.Following extensive discussions regarding the surgicaloptions, T.R. underwent reconstruction of both lips andnose with a free vertical rectus abdominis myocutaneous(VRAM) flap. Preoperatively, the deep inferior epigas-

tric vessel (DIEV) perforators were identified using ahand-held Doppler flowmeter, and a right VRAM flapwith a 15 · 5 cm skin paddle was marked out. The flapwas raised in the conventional manner. Then, the twomain divisions of the DIEV were identified and, underdirect vision the rectus muscle was split cranio-caudallyto a point just distal to the bifurcation of the main trunk(Fig. 2). Thus the lateral half was supplied by the lateraldivision, and the medial part of the muscle and itsoverlying skin paddle were supplied by the medial rowof DIEV perforators. The upper and lower lip remnantscars were incised, and turned inward to provide a lin-ing. The flap was inset into the spared commissuremuscles, an end-to-end anastomosis of the left facial toinferior epigastric vessels was carried out, and themuscle was split skin-grafted. Thus the partially dividedrectus muscle formed the upper and lower lips, and theskin paddle formed the distal half of the nose. The nasalapertures were left closed at that stage.

In a second operation, the patient underwent debul-king of the VRAM flap and reconstruction of the nos-trils. The fat in the myocutaneous part of the flap wasremoved in order to recreate the nasal apertures, whichwere stented with nasopharyngeal airways. Two monthsfollowing removal of the stents, the nostrils stenosed andrequired another revision. Full-thickness skin grafts wereused to line the nasal floors, and nasopharyngeal tubeswere again inserted into each nostril. In a later opera-tion, an iliac crest bone graft was used to provide skeletalsupport for the nose, the nasal alae were adjusted, andnew stents were inserted into both nostrils.

The patient remains well, and has adjusted ex-tremely well postoperatively. He is satisfied with hiscurrent appearance (Fig. 3; taken 15 months afterinitial presentation), and is coping with his myoelectriclimb prostheses. There are no donor-site complica-tions. T.R. manages solid foods, although he is trou-bled by a mild degree of drooling due to a lack oflower lip height. His speech however, is satisfactory.

Department of Plastic and Reconstructive Surgery, Addenbrooke’s UniversityHospital, Cambridge, UK

*Correspondence to: Mr. Navid Jallali, 9 Chinegate Manor, 39 KnyvetonRoad, Bournemouth BH1 3QJ, UK. E-mail: navidjallali@hotmail.com

Received 15 March 2004; Accepted 11 August 2004

Published online 4 February 2005 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/micr.20090

ª 2005 Wiley-Liss, Inc.

DISCUSSION

This case posed a significant reconstructive challengedue to the substantial defects of the nose and lips and thelack of conventional free-flap donor sites. A combina-tion of locoregional flaps (e.g., a Gillies forehead flap tothe nose, inferiorly based von Bruns’ nasolabial flaps tothe upper lip, and labiomental flaps to the lower lip) wasput forward as one option. However, the patient wasdetermined to avoid any further facial scars and refusedto provide consent, despite being assured that the num-ber of scars does not necessarily determine the finalcosmetic outcome. Therefore, the only option availablewas free tissue transfer, but the below-elbow and below-knee amputations meant that radial forearm and dorsalispedis free flaps could not be used. Reconstruction of thenose and both lips using a VRAM flap was thereforeattempted. In hindsight, we think that the nose shouldhave been reconstructed with a separate forehead flap.This probably would have given a better cosmetic resultand avoided the problems of recurrent nostril stenosis.

The use of a VRAM flap for reconstruction of bothlips is a viable option, as anatomical studies have con-firmed that splitting the rectus muscle is usually feasible.In a cadaveric study, El-Mrakby and Milner12 demon-strated that the DIEV ascends as a single trunk, afterwhich it divides into 2 branches in 80% and 3 branches in20% of individuals. Thus splitting the muscle to form theupper and lower lip should be possible in the majority ofcases. Intraoperatively, the branches of the DIEV can beidentified by inspecting the deep surface of the rectusabdominis muscle. Splitting the muscle to the bifurcationof the DIEV can then be safely carried out under directvision.

It may be argued that using a single flap to recon-struct two sites violates basic reconstructive principles.

However, we believe that the VRAM flap confers cer-tain advantages over traditional techniques. First, thereis only a single donor site, as both the upper and lowerlips can be reconstructed with one flap. Second, thedonor-site scar is inconspicuous when compared to theRFFF. Finally, there is no need to turn the patient in-traoperatively, as the flap harvest can be undertakensimultaneously with preparation of the vessels. Themain disadvantage of this flap is that its bulky naturegives a poor immediate postoperative appearance. Fur-thermore, it requires judicious debulking, as the musclecan undergo considerable atrophy, which led to a lack oflower lip height in this patient.

While locoregional flaps and the RFFF should re-main the primary options for lip reconstruction, theVRAM flap could be part of the surgeon’s armamen-tarium, particularly when conventional donor sites areunavailable.

Figure 1. Photograph of face shows extensive gangrene of nose

and both lips.

Figure 2. Intraoperative photograph shows splitting of rectus abdo-

minis muscle (ventral view).

VRAM Lip and Nose Reconstruction 119

ACKNOWLEDGMENTS

The authors thank Mr. George C. Cormack, Con-sultant Plastic and Reconstructive Surgeon at Adden-brooke’s Hospital, for suggesting the use of this flap.

REFERENCES

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Figure 3. AP (A) and lateral (B) view of final appearance.

120 Jallali and Malata