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Lower Lip Reconstruction: Introduction of a New Procedure Using a Functioning Gracilis Muscle Free Flap

Background: Subtotal and total reconstruction of the lower lip is a challenge for the plastic surgeon: this lip mainly contributes to the continence function of the oral sphincter. Fasciocutaneous free flaps and local flaps are better suited to the skin laxity of elderly patients; furthermore, larger defects extending to the chin area can be difficult to manage with only local flaps. Methods: In an attempt to restore very good function and aesthetics of the lower lip in a single procedure, the authors introduced the use of a functioning (innervated) gracilis free flap. The dynamic sphincter capacity was obtained with the coaptation between the motor branch of the gracilis muscle and the marginal branch of the facial nerve. A facial artery musculomucosal flap replaced the vermilion and the inner side mucosa, and a skin graft from the scalp covered the external surface of the gracilis. The procedure was performed in two cases. Results: In both cases, the authors achieved quite full physiologic lower lip movement with regard to symmetrical spontaneous and voluntary controlled lower lip function, whereas the skin grafts from the scalp and the supraclavicular region had a nearly perfect color match with the reconstructed area. The aesthetic result was excellent compared with the complexity of the reconstructed defect. Conclusions: A functioning gracilis free flap has to be considered among the techniques for complex lower lip reconstruction. It was able to restore very good voluntary function and an extremely fine aesthetic result in a single-stage procedure.