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Print version ISSN 0365-0596
An. Bras. Dermatol. vol.86 no.4 supl.1 Rio de Janeiro July/Aug. 2011
Karapandzic flap and Bernard-Burrow-Webster flap for reconstruction of the lower lip*
Ana BrincaI; Pedro AndradeI; Ricardo VieiraII; Américo FigueiredoIII
IPhysician, Intern in Dermatology - Service of Dermatology - Hospitais da Universidade de Coimbra - Coimbra, Portugal
IISpecialist in Dermatovenereology - Hospital Assistant in Dermatology - Hospitais da Universidade de Coimbra - Coimbra, Portugal
IIIProfessor PhD - Chief of the Dermatology Service - Hospitais da Universidade de Coimbra - Coimbra, Portugal
Squamous cell carcinoma is the most common malignant neoplasm of the lips, and in about 90% of cases it is located on the lower lip due to higher cumulative exposure to ultraviolet radiation. The authors present two surgical techniques for reconstruction of large lower lip defects, resulting from surgical excision of tumors, exemplifying and comparing them with two clinical cases.
Keywords: Carcinoma, squamous cell; Lip neoplasms; Surgical flaps
Squamous cell carcinoma in the most common malignant neoplasia of the lips and in 90% of the cases it is located on the lower lip, due to higher cumulative exposure to ultraviolet radiation, the main etiopathogenic aspect .1,2 Other possible contributing facts are smoking and drinking habits, immunosupression and chronic infection by the human papiloma virus. The mainstream treatment is surgical excision with adequate clear margin. Due to the functional and cosmetic importance of the lips, the reconstruction of resulting defects is a challenge. There are various reconstructive procedures to be selected from, according to the size and location of the defect, characteristics pertinent to the patient (associated morbidities) and experience of the surgeon. 3-5
For small tumors surgery is the preferred treatment, as it results in good cosmetic and functional outcomes and provides material for histological analysis, thus allowing for the evaluation of the complete excision of the neoplasia, which is not possible with radiotherapy. The most commonly used technique is the excision in ellipse with direct closing, with or without associated vermillionectomy. For bigger tumors, when the surgical excision will result is a defect of more than 50% of the length of the lip, other techniques are used, like the Karapandzic flap 6-8 and the Bernard-Burrow-Webster flap 9,10, the methods chosen by the authors in the present cases. Both methods are used to treat the defect caused the excision of squamous cell carcinoma of the lower lip and both show good clinical, functional and cosmetic results, thus being considered good therapeutic options.
CASE 1: 57 year old male, smoker since the age of 7 years, with a history of 40 units-pack-year, with moderate alcohol consumption and poor dentition. He presented with an infiltrated, ill defined, slightly raised plaque, with irregular borders and an eroded, crusty surface, measuring 2.5 cm along the longest axis, covering the medial third of the vermillion of the lower lip (Figure 1). The lesion had been present for 6 months. There was no palpable regional adenopathy. The clinical diagnosis of squamous cell carcinoma was confirmed by incisional biopsy.
The patient was submitted to radical surgical excision of the lesion, resulting in a full- thickness defect of more than 50% of the length of the lower lip. The reconstruction was performed using the Karapandzic technique, based in two sliding-rotation flaps. The technique consists of making two incisions on either side of the mouth, beginning on the inferior borders of the surgical defect and prolonged by the mentolabial and nasolabial creases (Figure 2). The orbicularis oris muscle was freed from the neurovascular structures on either side of the comissures, allowing the rotation of two myocutaneous flaps, thus preserving the sensibility and mobility of the lip (Figure 3).
The flaps were mobilized medially and the mucosa, the orbicularis oris and the skin were closed in three successive layers, preserving the continuity of the orbicularis oris, and thus the function of the oral sphincter.
The cosmetic and functional results were satisfactory, as the sutures followed the natural creases; the oral function was preserved as well as the sensibility and mobility of the lips (Figure 4). However, there was a slight microstomy, without any functional impact (Figure 4).
The patient was followed by three years without any sign of local recurrence or loco regional metastases.
CASE 2: 43 years old male, 35 units-pack-year smoker, with marked alcohol consumption, referred to the consultation because of an ulcerated 3cm tumor located on the median third of the lower lip vermillion, which was present for 7 months (Figure 1). The incisional biopsy showed a squamous cell carcinoma. There was no palpable regional adenopathy.
The radical excision of the lesion resulted in a full thickness median defect involving around 60% of the length of the lower lip. In this case, because the defect was bigger, the reconstruction using the Bernard-Burrow-Webster technique was chosen, using two sliding flaps (Figure 5). Two full thickness incisions were made laterally to the comissures, slightly curved upwards, each one around half the length of the surgical defect. Two other smaller incisions were made from the inferior extremities of the surgical defect, at the level of the mentolabial crease, slightly curved downwards (Figure 5). This resulted in two roughly square flaps that were then sutured at the median line, by layers (mucosa, muscle, skin). The Burrow triangles over the nasolabial creases were excised, however the deepest layer, the mucosa, was preserved and sutured to the superior border of the myocutaneous flap in order to rebuild the new vermillion. Before excising the lateral and medial sides of the mucosal triangle the opening of the Stenon canal was identified, this way avoiding its accidental damage (Figure 5).
In this second case we observed a contraction of the lower lip as a complication of the surgical procedure (Figure 6).
So far the patient has had a 4 years follow-up and has been free of the disease, local recurrence and loco regional metastases.
The Karapandzic flap6-8 and the BernardBurrow-Webster flap9-11 are two of the most used techniques for the reconstruction of big lip defects, having the advantage of being one-step surgical procedures. The Karapandzic flap is suitable for defects that take 1/3 to 2/3 of the length of the lower lip. With bigger defects, the resulting microstomy limits the procedure. With total or subtotal lip defects, unlike the former technique, the Bernard-Burrow-Webster flap is a good option for reconstruction. While the BernardBurrow-Webster flap usually requires general anaesthesia, the Karapandzic flap can eventually be performed under loco regional anaesthesia.
The biggest advantage of the Karapandzic flap is the preservation of the mobility and the sensibility of the lower lip, as well as of the oral continence. However, it can cause microstomy (which can require corrective plastic surgery of the comissures in case it has a big impact on the patient's life or in those with dental prosthesis) and distortion of the oral comissures.12 The Bernard-Burrow-Webster flap, despite not causing microstomy, usually results in some incontinence of the oral sphincter 11, particularly at the comissures. Besides, it can cause a misplacement of the lower lip in relation to the expected position.
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Mailing address: Received on 18.07.2010. * Work performed by: Dermatology Service - Hospitais da Universidade de Coimbra - Coimbra, Portugal.
Hospitais da Universidade de Coimbra
Serviço de Dermatologia
Praceta Dr. Mota Pinto
3000-075 Coimbra, Portugal
Tel.: 0035 12 3940 0490
Approved by the Advisory Board and accepted for publication on 12.10.2010.
Conflict of interest: None
Financial funding: None
Received on 18.07.2010.
* Work performed by: Dermatology Service - Hospitais da Universidade de Coimbra - Coimbra, Portugal.