Gottfried Lemperle
Christoph Sachs
Katja Kassem-Trautmann
Carsten Schröder
Jörg Kalla
Gottfried Lemperle
Gottfried Lemperle
Katja Kassem-Trautmann, Plastic Surgeon, Zug, Switzerland
Arthur Charpentier1, Gottfried Lemperle2
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Arthur Charpentier1, Gottfried Lemperle2
Received: 21 March 2016 / Accepted: 31 July 2016 / Published online: 13 September 2016
© Springer-Verlag Berlin Heidelberg 2016
There are many ways to reconstruct a missing upper or lower lip. Most textbooks and articles describe vertical nasolabial flaps, horizontal frontal flaps, or platysma flaps, from the neck (to be used mainly for inner lining) [1, 2] Distant flaps from the upper arm (Tagliacozzi), musculocutaneous latissimus flap (used in noma repair, or free microsurgical flaps from the forearm (Chinese flap) can serve as a large frontal flap to prevent further mutilation of the face. However, this most simple and cosmetically effective reconstruction of an upper lip has not been described before.
Two young men were presented to a team of Interplast-Germay operating in Goma. They had been tortured by marauding soldiers in the rain forests North of Goma. They had been tortured by marauding soldiers in the rain forests North of Goma, in the Democratic Republic of Kongo. When the men denied havaing gold, the soldiers sequentially amputated their sumb, fingers 2 and 3, and both ears. In raiding their hut, the soldiers then found a few gold nuggets. As punishment, they proceeded to cut off upper and lower lips of both men.
When presented to us, the wounds around the missing lips and ears appeared clean; the finger stumps had been closed surgically. Understandably, both men, aged 23 and 30, were severly traumatized and could only be examinaed with difficulty.
The lips of both patients were amputated entirely and almost professionally between cheeks, nose and chin (Figs. 1 and 2). First, a large horizontal frontal flap was discussed but rejected, since a dark black skin graft would have further disfigured the faces. A free forearm flap was out of question because of a lack of surgical loupes. Therefore, we decided on utilizing local flaps, although the remaining skin of the cheeks appeared very tight.
Under general anaesthesia, the full-thickness cheeks with the residual mucosa were undermined on the bony level along the maxillary arches back to both mandibular joints. Square flaps were cut between nose and lower lids and pulled together in the midline below the columella. The skin with some facial muscles complete with inner lining could be pulled towards the midline to cover the upper teeth.
For the reconstruction of the lower lips, a reverse 4-cm visor flap from under the chin, including the patysma, was designed and pulled over the chin. The donor defect was closed after undermining the neck skin. For the inner lining, two vertical mucosal check flaps (2 x 4 cm) with their base in the lower gingival fold could be raised and pulled to the midline.
All flaps healed well, but the constant tension on the wounds opened the view to the frontal teeth again in the younger man. Surprinsingly, after 3 months, the upper lip of both men was fully sensitive and the lower lip felt pain during squeezing. SLight muscle movement could be detected in all lips.
Gottfried Lemperle
Lemperle8@aol.com
Arthur Charpentier
charpentierarthur@gmail.com
Fig. 1 The 30-year-old patient before lip reconstruction and skin grafting around the lost ears
Fig. 2 One year after bilateral cheek advancement for upper lip reconstruction, and a reverse visor flap from the neck, and two vertical mucosal flaps for inner lining, and four days after widening of the mouth surgical opening the mouth.
The same Interplast-Germany team operated a second time on the two patients: the older of the two men required a wider opening of his mouth which was easily achieved under local anaesthesia (Fig. 3). The younger man required a second undermining of both cheeks under general anaesthesia in order to bring enough skin towards the midline (Fig. 4). Both corners of his mouth became infected and opened again, but could be closed on day 5 and healed well with the help of local applications of cefazolin powder ans systemic cefazolin infusions.
The literature reveals few recommendations for total lip reconstruction after radical removal of both lips. In most cases, a patient had lost an upper or lower lip from cancer, trauma or dog bite, which could be reconstructed with two or three local flaps from the loose surrounding soft tissue [1, 2].
Experience and availability of microsurgery will give preference to a free flap [3, 4]. A free composite forearm flap with the inclusion of a vascularized palmaris longus tendon has been an effective way of total lower lip reconstruction. Both ends of the vascularized tendon were laid through the bilateral modiolus and anchored with adequate tension to the intact orbicularis muscle of the upper lip [5].
Should a reconstructed lower lip drop over time, a long fascia lata strip could be inserted and fixed with both ends to each severed mandibular process, as it is done in patients with Moebius syndrome according to the Mc Laughlin procedute [6].
In a similar case to ours, a patient with large defects after cancer removal from both lips was covered with many local flaps [7]: the aesthetic result, however, was less convincing than ours (Figs. 3 and 4). A recent publication concerned a patient without upper lip following complete resection for squamous cell carcinoma; bilateral nasolabial flaps, submental flap, and mucosal grafts were used [8].
In another case, describing a patient with both lips completely lost to noma (we suspect trauma), a large split visor flap from the forehead was rotated downwards and split to reconstruct both lips with moustache and beard, resulting in an aesthetically very pleasing outcome [9]. A functional and cosmetically preferable alternative for our younger patient might have been a partial face transplant, since he had an almost identical defect as a female patient in Amiens (2005), who lost nose and lips to a dog bite [10]-
Fig. 3 The 23-year-old patient with the same mutilations, yet a more extensive resection of both lips
One year after the same procedures and four days after a second advancement of both cheeks. Furter opening of the mouth will be done in 3 weeks.
African states with a long history of revolution have a problem of re-integrating soldiers, who have deserted their army to join the rebels. Rebels who surrender or make peace with the government - as in Kongo in 2003 - have not been allowed to rejoin the army. These former soldiers have no other skills but to shoot, torture, and kill. This is the reason why the torture is afflicted on our two patients will continue for some time.
Acknowledgments We thank Miss Lydia Kerr, Naples FL, for revising the manuscript. We also thank Dr. Thomas Biesgen, Tier, and Dr. Michaela Hladik, Salzburg from Interplast-Germany for assisting in the first operations.
Compliance with ethical standards
Ethical standards For this type of study formal consent from a local ethics commitee is not required.
Conflict of interest Arthur Charpentier and Gottfried Lemperle declare that they have no conflict of interest
Patient consent The illiterate patients provided verbal consent to G.L. for the inclusion in this study and use of their images.
Funding None
References