Correction of Lower Lip Malposition with Fascia Lata Slings Following Anterior Mandibular Resection

INTRODUCTION

Lip incompetence can result from the resection of the anterior mandible due to loss of soft tissue and muscular attachments of the lower lip to the mandible and obliteration of the anterior gingivobuccal sulcus. The resulting lip ptosis and malposition lead to an inability to create an oral seal despite an intact orbicularis oris. This results in constant drooling at rest and food leakage while eating. Patients start avoiding normal social activities, such as eating at restaurants and going out in public, resulting in social isolation.

We have used fascia lata slings to correct lip ptosis after free-flap mandible reconstruction. Suspension of the lower lip with tendon or fascial slings is an established technique for total lip reconstruction and facial paralysis; however, the use of fascial slings has not been previously reported for the correction of lip incompetence after anterior mandibular resection and reconstruction with a bony free flap. In this article, we describe our surgical technique.

Methods/Surgical Technique

The following is a brief overview of the steps of the operation.

Markings: Surgery is performed under general nasotracheal anesthesia. Two-centimeter incisions are marked immediately behind the temporal hairline. A straight line is drawn from the temporal marks to the oral commissure. The red line (junction of wet and dry vermilion) of the lower lip is marked (Figure 1).

Fascia lata harvest: The length of the fascia needed is determined by adding the length of the cheek and lip markings, plus a few centimeters. Step incisions are made for harvesting a 1.5-cm-wide strip of fascia lata from the lateral thigh. This strip is turned into a roll by rolling it longitudinally and suturing it to itself with a 4-O polypropylene suture (Figure 2).

Deep temporal fascia exposure: The deep temporal fascia is exposed on both sides by making a 2-cm incision in the temporal scalp at the previous markings.

Creation of tunnels: A 1-cm transverse incision is made just lateral to the oral commissure. A subcutaneous tunnel is created between the oral commissure incision and the temporal scalp incision at the previously marked line. A submucosal tunnel is created in the lower lip along the previously marked red line.

Passage of fascial graft through tunnels: The fascia lata roll is passed through the lower lip submucosal tunnel via the previously made bilateral oral commissure incisions (Figure 3). Each end of the fascial roll is then passed through the cheek subcutaneous tunnels and into the temporal opening.

Tensioning and inset: The cranial ends of the fascial roll are pulled to set the lip height in a slightly overcorrected position. The fascial grafts are sutured to the deep temporal fascia using “0” polyester sutures.

Results

The above technique was used in two patients who developed lip malposition after oncologic anterior mandibular resection. The patients provided informed consent for surgery and the use of their full-face pictures. Institutional review board permission was obtained.

Clinical Case 1

An 80-year-old female underwent angle-to-angle mandible reconstruction with a fibular osteomyocutaneous free flap. Post-operatively, there was a 25% loss of the skin paddle, which required a radial forearm free flap. She developed lip malposition, which was exacerbated by adjuvant radiotherapy. A fascia lata sling was performed, which corrected lip position and drooling.

Clinical Case 2

A 77-year-old female underwent angle-to-angle mandibular reconstruction using a fibula osteomyocutaneous free flap. Adjuvant radiation resulted in osteoradionecrosis, which required another fibular flap. She developed malunion of the fibula to the radiated mandibular ramus, leading to fibula flap malposition, resulting in an open-mouth deformity and lip ptosis. A fascia lata sling was placed, which resulted in cessation of drooling at rest and during eating.

Conclusions

Resection of the anterior mandible can result in lip malposition due to loss of its soft tissue and muscular attachments. Lip position can be improved by cranial suspension with a fascia lata sling. Restoration of lip competence results in cessation of drooling, improvement in eating, and restoration of facial aesthetics.