Sling suspension using anterior third of temporalis muscle extended with tendon graft
to correct incontinence after free flap reconstruction when there is a major defect of
lower lip muscle
Tsung-Chun Huang, MD, Tzong-Shiun Li, MD, Hui-ching Weng, PhD., Ka-Wai Liu,
MD , Ciudad Pedro, MD, Matthew Sze-Wei Yeo, MD, Hung-Chi Chen, M.D., PhD. ,
F.A.C.S
Department of Plastic and Reconstructive Surgery, China Medical University
Hospital, China Medical University, Taichung, 40447, Taiwan
Correspondence:
Professor Hung-Chi CHEN, MD, PhD, FACS
Division of Plastic Surgery, China Medical University Hospital, 2,Yuh Der Road,
Taichung City, 40447, Taiwan
Tel.: +(886)-4-2205-2121 ext 1509,1510
Fax: (886)-4-22029083
E-mail: D19722@mail.cmuh.org.tw
Abstract
Background: Oral incontinence is a common complication after free flap
reconstruction after ablation of oral cancers. The post-operative incontinence was
corrected with strong suspension to temporalis muscle when there is major or total
defect of lower lip muscles.
Patients and Methods: Eight oral cancer patients with previous skin flaps for
reconstruction of lower lip had incontinence due to major or total loss of lower lip
muscle. A tendon graft was used as suspension sling sutured to the anterior third of
bilateral temporalis muscle.
Results: Oral continence without drooling was achieved by suspension to temporalis
muscle with free movement of lower lip.
Conclusion: This is a good option for correcting the incontinence after major or total
loss of lower lip muscles in oral cancer patients.
Introduction
Through-and-through complex defect of lower lip and cheek after head and neck
surgery are still challenges for reconstructive surgeons[1]. Following tumor ablation,
major burn [2], or ballistic trauma [3], major loss of orbicularis muscle of lower lip
frequently results in oral incontinence, speech problem, and accompanied social
disturbance. One-stage reconstruction of lower lip is achieved by local flap for small
defects, or by free flap reconstruction for major defect. To avoid post-operative oral
incontinence, several series have been reported by means of free flap combined with
palmaris longus, or tensor fascia lata static suspension. However, only few dynamic
reconstruction techniques were described in some limited circumstances[1, 2, 4, 5].
We demonstrate a new surgical approach to correct oral incontinence with mimicing
dynamic reconstruction (Video 1). Lower lip is strongly suspended by tendon graft,
which is fixed to bilateral anterior third temporalis muscles. This method not only
provides mouth opening and closure but also has the potential of popular use for
either fresh or refractory cases.
Patients and Methods
All patients have oral incontinence with drooling resulting from a major loss of
orbicularis muscle of lower lip. Three patients had simple free fasciacutaneous flap
before, and the other five patients had serial complicated free flap reconstruction,
such as free fibula osteocutaneous flap, free latissimus dorsi (LD) with serratus
anterior (SA) and rib flap, free anterolateral thigh (ALT) flap, pedicle pectoralis major
(PM) flap, and pedicle deltopectoral (DP) flap. Adequate release of contracture,
debulking procedure, and commissuroplasty were performed individually before sling
suspension technique as described below.
Operation Technique
Tendon graft was harvested with a tendon stripper from plantaris, palmaris
longus, or extensor tendon of second (or third) toe. One incision about 3 to 5
centimeters was placed within the temporal hairline. Dissection was performed to
expose the temporoparietal fascia and deep temporal fascia. The elevator was then
placed in a plane between the deep temporal fascia and temporalis muscle to create a
tunnel headed to ipsilateral oral commissure by blunt dissection. Another small
incision was made at the ipsilateral oral commissure. A subcutaneous tunnel was
created along lower lip in the previously transferred fasciacutaneous flap (Figure 1).
The tendon graft traveled from anterior third of temporalis muscle on one side and
then passed through the subcutaneous tunnel of the flap to the other side. According to
the severity of oral incontinence, adequate tension of suspension was adjusted to
make mouth closure without limitation under general anesthesia. Eventually, the
lower lip was suspended by anchorage with 3-0 Prolene Pulvertaft sutures.
Cases presentation
Case 1
A 64-year-old male presented with lower lip chronic ulcer and frozen section
reported malignancy (Figure 2A). Clinical stage was cT4N0M0 by computer
tomography. He underwent wide excision of the tumor resulting in total lower lip
defect. The defect involved 100 percent loss of orbicularis oris muscle in the lower lip.
The pathology revealed squamous cell carcinoma (pT1N0M0). One-stage
reconstruction with free anterolateral thigh flap was performed (Figure 2B). Three
months later, oral incontinence with saliva leakage led to poor oral intake and social
disturbance. The extensor tendon of left third toe was harvested with a tendon stripper
and then sutured to bilateral anterior third temporalis muscles. After lower lip
suspension procedure as described above, oral continence was achieved by dynamic
suspension without loosening at 2 years and 5 months of following-up (Figure 2C, 2D,
Video 1). He can eat solid diet without limitation.
Case 4
A 47-year-old male had double cancers with serial reconstructions in the past ten
years. Ten years ago, he received right partial glossectomoy for right tongue
squamous cell carcinoma without flap reconstruction, followed by post-operative
radiation therapy (6300cGy /35Fr) for two months. Four years after the first cancer,
another squamous cell carcinoma (cT4N0M0) was found over left anterior lower
alveolar ridge, then he received tumor ablation and left segmental mandibulectomy
with anterolateral thigh (ALT) flap reconstruction. Post-operative radiation caused
stricture of oropharynx. Therefore, serial reconstructions were done including
uvulopalatopharyngoplasty and free radial forearm for mouth floor and oropharynx,
free fibula flap for bilateral mandible reconstruction due to exposure and
dislodgement of the reconstruction plate, and right pedicle deltopectoral flap for
coverage of the residual defect of right chin soft tissue. However, he still suffered
from right oral commissure drooling (Figure 3A, 3B). We performed the suspension
procedure as described above. Ultimately, the oral incontinence was completely
corrected (Figure 3C, 3D).
Case 6
A 71-year-old male had left retromolar squamous carcinoma (T4N1M0) ten
years ago and reconstruction with free fibula osteocutaneous flap was performed.
However, the cancer recurred twice. He received wide excision and reconstruction
using free latissimus dorsi flap with rib in the first time, and anterolateral thigh flap in
the second time. Total loss of lower orbicularis muscle caused a huge defect when he
tried to close his mouth (Figure 4A, 4B). We performed the suspension procedure
with tendon graft. Four months later, oral competence was achieved. He could take
punched food smoothly (Figure 4C, 4D).
Results
All patients were male with mean age 64.9 years (range, 47-81 years) (Table 1).
The average defect of lower lip was 86.3% (range 60-100%) of the lower lip. Two had
early cancer stage (I-II), four patients had advanced cancer stage (III-IV), and the
other two did not have the record of their initial cancer staging because they were
referred from other hospital. Our preferred tendon graft was plantaris tendon which
was harvested from four patients. If plantaris was not available, the extensor tendon of
second or third toe would be chosen. Palmaris longus tendons were selected in two
patients along their previous wound scar of radial forearm flap. It was split to 2 strips
to achieve enough length. The only donor site morbidity was ulcer near the ankle with
cellulitis in case 7. All patients had dynamic movement of the lower lip after
reconstruction, and completely achieved their oral continence without drooling
post-operatively. The mean follow-up time was 7.9 months (range 1- 29 months).
Four patients could take soft or full diet and the others could take liquid diet due to
lack of tooth or narrowing of oropharynx.
Discussion
Ideal lower lip reconstruction requires aesthetic and functional restoration. Small
to moderate sized defect of lower lip can be treated with local flap or primary closure
[1, 6-8]. When a major defect occupying more than 60 to 80 percent of the lower lip
[8, 9], free tissue transfer will be the optimal option, especially in the lesion involving
through and though defect over cheek and lower lip. In static lower lip suspension and
reconstruction, composite radial forearm-palmaris longus (PL) free flap is a common
method. Sakai et al. [10]and Sadove et al. [11] introduced this application about
twenty years ago, but the post-operative drooling is inevitable. Jeng S.F. et al. [7]
improved this morbidity by modifying the insertion site of PL tendon which was
passed through modiolus and inserted to orbicularis oris muscle near philtral columns.
Anterolateral thigh (ALT) flap with fascia lata suspension was also performed in
lower lip cancer[8] and large through-and-through defect[1, 9]. However, all of the
above did not provide adequate dynamic motion especially when there is a major or
total defect of the lower lip, and are apt to loosen after speaking and eating [8].
In the past, a true dynamic suspension was thought to be achieved only by
functioning muscle transfer. Few muscle flaps were reported in limited circumstances.
Kushima et al. reported that a combination of radial forearm flap and depressor anguli
oris muscle transfer can effectively preserve the sphincter function of lower lip[12].
However, this method is not reliable in advanced stage in oral cancer since the
depressor anguli oris muscle may have been sacrificed during tumor ablation[5].
Masseter muscle[13] transfer has also been described, but it is still limited when the
residual orbicularis muscle is too far away from reaching[2]. Recently, temporalis
muscle transfer has become a new alternative option. The temporalis muscle remains
intact even in advanced lower lip cancer so as to obtain satisfactory oral sphincter
function when it is combined with free radial forearm flap[5]. In major burn or
ballistic trauma, temporalis muscle flap and fascia lata grafts can be used for good
suspension, except for the risk of temporal hallowing and facial nerve injury[3].
Better dynamic functional restoration may be derived from free gracillis muscle
transfer[14], but it is a more technically demanding operation.
Surgeon can accomplish suspension accompanied with liberal motion of lower
lip more easily by tendon graft strongly anchored to bilateral anterior third temporalis
muscle. Mouth opening was performed by bilateral lateral pterygoid muscle, which
was intact during tumor ablation. That is the reason why our patients can open their
mouth without limitation. Once they want to close his mouth, medial pterygoid,
masseter, and temporalis muscle will contract. Meanwhile, our tendon sling
suspension will serve as a strong passive spring to lift the lower lip to accomplish oral
continence. A vividly symmetric motion of the lower lip was provided. Based on
temporomandibular joint as a fulcrum, our suspension will produce more powerful
torque than static sling suspension to orbicularis. This mechanism explains why two
recurrent cases (case 6,7) in our series could restore oral competence after serial
reconstruction and radiotherapy. As the treatment in head and neck cancer is
improving, more and more patients will need this technique to correct their
incontinence after multiple reconstructions. Our new surgical procedure has more
potential for widespread application since it can be performed in fresh patient with
major lower lip defect and even in patients with recurrences of cancers. Oral
incontinence can be corrected directly after the operation. With the strong suspension,
patient can start to rehabilitate the motion of mouth opening after removing suture at
two weeks. Besides, tendon was more effective with less chance of loosening than
tensor fascia lata graft. No infection was found in the recipient sites of tendon grafts.
There are still some limitations in our series. The mean follow-up time was 7.9
months (range 1- 29 months), which is not long enough to rule out the possibility of
loosening. The other disadvantage is to require one additional donor site of tendon
graft, but no patient had decreased range of motion of the ankle. Only one patient had
ulcer near the ankle, which healed after conservative treatment. Two-stage
reconstruction is preferred, namely providing adequate lower lip soft tissue in the first
stage, and correction of incontinence after wound healing to prevent tendon graft
infection. This is a good option to treat refractory cases of lower lip incontinence with
the suspension method.
Conclusion
Tendon sling anchored to bilateral temporalis muscle provides adequate
suspension in lower lip reconstruction following ablation of oral cancer with total or
major loss of orbicularis muscle in the lower lip. This method can correct oral
incontinence and achieve liberal movement of lower lip.
Reference
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