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Page 4 of 6 Al Shetawi et al. Plast Aesthet Res 2018;5:1 I http://dx.doi.org/10.20517/2347-9264.2017.61

A B

Figure 4. (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 improves the lip-to-tooth relationship

Numerous techniques of vestibuloplasty are available to lengthen the vestibule such as submucosal
vestibuloplasty, open vestibuloplasty with secondary re-epithelialization, transpositional vestibuloplasty
[1]
and skin grafting . In the irradiated patient, these techniques have a limited role due to the poor vascular
supply, scaring and fibrosis and limited tissue laxity. The unpredictable outcome of these procedures also
carries a significant risk for hardware exposure, poor healing and wound dehiscence. Pedicled flaps using
[2,3]
the facial artery myomucosal flap and the nasolabial flap have been used in the past . However, in the
post-ablative irradiated patient, these flaps have limited role due to the limited amount of tissue available
for transfer, the need for intact facial artery which is often compromised after ablative surgery, and the
[4]
presence within the zone of external beam radiation .

The deformity of the recalcitrant upper lip results from skin, muscle and mucosal tissue loss and fibrosis.
Therefore, full-thickness reconstruction is essential to restore the length and thickness of the upper lip and
re-establish the maxillary vestibule. Vascularized free tissue provides the best method of reconstruction in
these patients.

[4]
St-Hilaire et al. described 13 patients with intractable vestibules secondary to tumor extirpation,
traumatic injuries and infections. They used the ulnar and anterolateral thigh flap to reconstruct the oral
vestibule. In our case series, the patients had lip and vestibular deformity secondary to tumor extirpation
and/or radiotherapy. In two patients, the deficiency of soft tissue was full thickness, and required tissue
augmentation to the mucosal and cutaneous surfaces to allow lengthening of the lip and vestibule. We
chose the RFFF which was ideal to provide thin and pliable tissue with a long vascular pedicle. It also
allowed complex design of the skin to resurface the mucosal and cutaneous linings.

The flap is harvested in the standard technique. The skin is de-epithelialized in the middle segment [Figure 6].
The recipient site is prepared by making an incision at the depth of the vestibule to release the upper lip.
Another incision is made at the base of the nose to allow lip lengthening. The two incisions are connected
and the area is widely undermined to allow the flap inset. The de-epithelized segment is tunneled and the
epithelized segments are inset at the base of the nose to lengthen the lip, and the depth of the vestibule to
lengthen the neo-vestibule [Figure 1B].

Subjective outcome assessment was performed in all patients. All patients were satisfied with final aesthetic
improvement. All patients were able to wear dental prosthesis and had improved lip competence, speech,
mastication and bolus control.

We recognize the limitations of this study which include the retrospective case series design and the
subjective outcome assessment. The purpose of this study was to demonstrate a surgical technique which
is useful in a challenging clinical problem. This case series highlights the importance of secondary
refinements after primary reconstruction and radiation therapy to improve the aesthetic and functional