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Al Shetawi et al. Plast Aesthet Res 2018;5:1 I http://dx.doi.org/10.20517/2347-9264.2017.61 Page 3 of 6

A B C

Figure 2. (A) The classic appearance of the shortened and retracted upper lip after primary reconstruction and adjuvant radiation therapy;
(B) inset of the radial forearm free flap lengthens the lip and vestibule; and (C) allows placement of dental prosthesis with improved lip-
to-tooth relationship

A B C

Figure 3. (A) Significant shortening of the upper lip and loss of vestibule after subtotal maxillectomy; (B) inset of the radial forearm free
flap at the depth of the neo-vestibule; (C) final appearance with improved lip-to-tooth relationship

Case 2
This is a 60-year-old female with a history of verrucous carcinoma of the anterior maxilla. She underwent
subtotal maxillectomy and bilateral neck dissection. She developed a shortened and retracted upper
lip with intractable vestibule [Figure 3A]. She was unable to wear a dental prosthesis. Subsequently she
underwent iliac crest bone graft and radial forearm free flap to reconstruct the recalcitrant upper lip and
oral vestibule [Figure 3B]. The postoperative course was unremarkable. Flap debulking was performed
at a later stage. She was able to wear dental prosthesis and had improved speech and mastication
[Figure 3C]. She was followed up for 3 years.

Case 3
This is a 57-year-old female with a history of squamous cell carcinoma of the right maxilla. She underwent
subtotal maxillectomy, neck dissection, fibula free flap reconstruction and adjuvant radiotherapy. She had
zygomatic implants. However, due to the loss of vestibule, dental rehabilitation was difficult. She underwent
multiple secondary procedures including fat grafting and vestibuloplasty. She continued to have the
classic appearance of the retracted and shortened upper lip on the affected side with intractable maxillary
vestibule [Figure 4A]. RFFF reconstruction was done to reconstruct the recalcitrant upper lip and oral
vestibule. The postoperative course was unremarkable. She subsequently had flap debulking to achieve
improved symmetry. She was able to wear dental prosthesis and had improved speech and mastication
[Figure 4B]. She was followed up for 6 years.

DISCUSSION
Ablative surgery disrupts the elegant anatomy of maxilla and the overlying soft tissue. Reconstructive
techniques in the primary setting are geared toward achieving bony and mucosal continuity [Figure 5].
Adjuvant radiotherapy leads to soft tissue atrophy and fibrosis. This results in upper lip retraction and
shorting, thinning of the vermilion and loss of the intraoral vestibule [Figure 1A].