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Kannan et al. Plast Aesthet Res 2018;5:4 I http://dx.doi.org/10.20517/2347-9264.2018.02 Page 5 of 6

Figure 7. Images of the labio-mandibular flap at 6-months’ postoperation showing excellent lip symmetry and orbicularis oris function.
Note the seamless functional and aesthetic outcome

time of suture removal with no acute or sub-acute complications. Longer-term, there were no instances of
microstomia while oral sphincter function was maintained in all cases. Lip symmetry was perfect in all but
one case where there was slight in-curling of the lip, requiring minor secondary revision. In spite of this, all
patients were satisfied with the seamless reconstruction following tumour removal. As regards completeness
of oncological resection, 100% of the tumours were completely excised with follow-up at 6 months showing
no signs of local recurrence.

DISCUSSION
Lip-based flap reconstructions have long been the primary like for like choice for lip defects, post-excision of
skin cancers but given their associated drawbacks viz. microstomia and the need for a two-stage procedure,
alternatives have been looked at. These include those based on the classical principles of local flaps e.g.
the double rhomboid flaps and variants of the Webster-Barnard flap . The former option is designed for
[4]
[3]
commissural defects while choice of the latter would still subject the patient to difficult mouth opening.
The advent of perforator flap know-how has provided a plethora of potential perforator flaps . One such
[5]
example is the modiolus perforator flap described by Gunnarsson and Thomsen wherein they describe
[6]
the use of a musculocutaneous perforator in a window of soft tissue bounded superiorly by the zygomaticus
major, inferiorly by the risorius, medially by the oral commissure and laterally, by the facial artery. This
consistent perforating vessel has been described by other studies and is the source perforator used for the
[7]
perforator-plus labio-mandibular flap. However, one of the issues with the use of propeller or islanded flaps
is the later onset of lymphoedema; an unaesthetic feature.

In order to overcome this, we have combined the best elements of the perforator concept and placed them
within the confines of traditional aesthetic sub-unit, which in this case, refers to the labio-mandibular
area. Placing the flap margins within these anatomical boundaries allows for the appearance of a scarless
technique. In addition, the preservation of a cutaneous bridge preserves lymphatic channels and minimises
lymphoedema. However, as the flap is rotated and advanced into the defect, the oral commissure is blunted.
A “Y-V” advancement of the oral commissure is then performed and advanced into the labio-mandibular
flap at its middle third. Partially dividing the flap here does not reduce its distal perfusion as the modiolar
perforator is preserved just distal to the Y-V advancement. This allows for an aesthetic reconstruction as
illustrated earlier in Figure 1.

Excising these tumours with a cuff of orbicularis oris muscle allows for completeness of cancer resection
while the remaining orbicularis oris muscle is sufficient to achieve an oral sphincter seal for functional
purposes. This also helps maintain the dimensions of the oral aperture, negating the microstomia effect. All
of these small steps contribute to an excellent functional and aesthetic outcome.