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Upper lip reconstruction post major cancer resections using the hybrid concept

Well established techniques such as bilateral Karapandzic’s (K) rotational flaps or Johanson’s stepplasty are capable of effectively reconstructing up to fifty percent of lip tissue otherwise microstomia would result. Dieffenbach’s bilateral advancement flaps from the cheek physically would reconstruct a bigger than fifty percent defect but lip would lose its mobility and sensation. Not all techniques described historically and theoretically can be applied to upper lip because from aesthetic point of view, it is totally a different unit.


INTRODUCTION
Lip functions include maintaining oral competence, speech, and communication. These tasks specifically oral continence has been studied objectively and thoroughly in the past. 1 Reconstructing the lip is considered best with local and regional tissues since it follows "like with like" basic principle of reconstruction.
Well established techniques such as bilateral Karapandzic's (K) rotational flaps or Johanson's stepplasty are capable of effectively reconstructing up to fifty percent of lip tissue otherwise microstomia would result. Dieffenbach's bilateral advancement flaps from the cheek physically would reconstruct a bigger than fifty percent defect but lip would lose its mobility and sensation. 2 Not all techniques described historically and theoretically can be applied to upper lip because from aesthetic point of view, it is totally a different unit. 3 In this study, we are demonstrating two cases with upper lip sub-total defects, reconstructed with the "hybrid concept" of combining K flaps with an Abbe flap.

CASE REPORT
Both cases in this article had their oncologic management addressed by the head and neck oncology multidisciplinary tumor board team. Surgical resection part of the lip tumor was carried out by a colleague head and neck surgeon, guided with frozen sections.

Case 1
A 55 years old woman diagnosed with adenocarcinoma. Preoperative inter commissure distance was 4.5 cm. A segment of 3.8 cm or over 80% full thickness of the central upper lip was resected (Figure 1a).

Case 2
A 70 years old woman was diagnosed with squamous cell carcinoma (SCC). Baseline inter commissure distance was 5.0 cm. She had 3.5 cm or a 70 % full thickness of her upper lip resected (Figure 4a). Similar plan and surgical steps were carried out in both cases Figure 1 (b-d), Figure 2 (a-c) and Figure 4 (b-e). The width of Abbe flap was determined keeping in mind expected remaining defect after K flaps been rotated, since it is known that bilateral K flaps would reconstruct close to fifty percent of lip defect. Raising the Abbe flap was done at first and its donor site closed. Upon raising the K flaps extra care was taken on the side of which Abbe flap's pedicle would be based upon. Peri-alar crescentic full thickness skin excisions were also carried out to aid in mobilizing the K flaps. All 3 flaps were brought together and repaired in layers. Flaps remained healthy. Abbe flap division and adjustment was considered in about 3 weeks.
Both cases eventually received postoperative radiation, however they did very well functionally. The Abbe flap provided a reasonable aesthetic replacement to the philtrum unit (Figure 3 a-c) and ( Figure 5 a and b).

DISCUSSION
All local reconstructive techniques depend on skin laxity and fortunately lack of elasticity. There are more techniques of lip reconstruction for cancer that are applicable to Lower lip, since it is more commonly affected and hence more commonly been reconstructed and studied. 2,3 Cleft lip surgery is an exception and a very specific kind of congenital anomaly.
Theoretically speaking many techniques can be applied to both upper or lower lips. However excellent techniques such as Johansson's step-plasty are not applicable to upper lip due to obvious reason of distorting aesthetic units otherwise. 6 In major lip defects, many free tissue transfer techniques including radial forearm flap with palmaris longus, have been described and evolved, and are considered as viable options for some surgeons. [3][4][5] But these carry the disadvantages of being barely a physical barrier with poor sensation, texture mismatch and the inability to replace a vermilion like tissue. 5 We have already introduced the "hybrid concept" of reconstruction in lower lip major defects, by rearranging the surrounding and regional soft tissues, using various concepts of flaps. 6 Uglesic et al, Gonzalez et al have also shared their experience of the lower lip large defects being reconstructed with different flaps. 7,8 Here we have demonstrated that on the upper lips, a similar concept is applicable, by carefully using a variety of maneuvers.
The percentage of a lip defect post resection is estimated based on the baseline inter commissure distance, since it is variable from one individual to another, and has been studied thoroughly in the past. 9 The two cases shown in the article, both had significant defect especially case 1, where approximately 80% of the upper lip was removed (only commissures were preserved).
The idea of incorporating Abbe flap obviously and initially came for the purpose of filling part of the large defect, and providing a unit mimicking the philtrum.
But it was noted during surgery, taking that shield shape flap from the lower lip worked more so like the concept of Burrow's triangle, helping in closure.
When bilateral K flaps are used for closure of a defect, it is a common observation, one would notice the opposing lip is somewhat crowded. Taking an Abbe flap makes all the sense, hence the fraise. When you are short of tissues, remove some more. Technically, raising the Abbe flap was done initially and under loupe magnification. Abbe flap requires more tedious dissection and learning curve compared to other regional flaps, it makes more sense to do that part first. Furthermore, we tend to avoid using adrenaline infiltration whenever doing an Abbe flap. The disadvantage of temporary limited oral opening and intake with an Abbe flap, is little in our opinion relative to what it gains at the end.

CONCLUSION
We believe the hybrid concept of upper lip reconstruction has the potential to provide optimum results both functionally and aesthetically in near total lip defects as well. Moreover, it represents an ideal concept for redistributing tissues in the lip region following major cancer resections; it is worth to be part of the armamentarium for the reconstructive surgeon.