IntroductionAny procedure for lip reconstruction should consider aesthetic as well as functional aspects. Ideal reconstruction should ensure adequate mouth opening, competence and cosmesis.

Many different surgical procedures have been described for reconstruction of lip carcinoma, including primary closure, mucosal advancement, local flaps and free flaps. However, in a low resource setting, reconstructive options are limited and we have to plan a procedure which is technically simple and cost effective, yet functionally adequate and cosmetically acceptable to the patient.

MethodsA 70 year old male smoker who had a previous history of primary carcinoma of the lip which involved the left oral commisure. This had been treated with wide excision and an Abbe Eslander flap reconstruction. He presented a second time with primary carcinoma of the lip now involving the right oral commisure. Due to his previous oral reconstructive surgery, he had pre-exisiting microstomia. He underwent wide excision of the new primary tumour which included disruption of his right oral commisure. Reconstruction was with mucosal advancement and primary closure of right side. Microstomia was corrected by converse commissuroplasty of the left oral commisure.

DiscussionIn an Indian setting, patients often present with an advanced stage of disease, continued use of tobacco products despite previous disease, and have significant financial constraints. For these patients, simple operative procedures which retain function, adequate mouth opening and acceptable cosmesis are necessary and desirable. Various reconstructive procedures for oral commissures have been described, beginning with Dieffenbach in 1831. This technique involved the advancement of superior, inferior, and lateral mucosal flaps to reconstruct the corner of the mouth after removal of a triangular wedge of scar tissue. The procedure was modified by Converse and later by Friedlander et al and Mehra et al.[2,3,4] Gillies and Millard, and later Johns et al, used the vermilion flap of the corner of the mouth to reconstruct the upper lip[1,5].They also used oral mucosa from the inner aspect of the lower lip to form a new vermilion border.

Microstomia following resection of malignancies of the lips and mouth has become uncommon with modern reconstructive techniques. However, the surgeon must understand which reconstructive techniques lead to a smaller oral aperture. As a rule, surgical techniques that do not recruit tissue to compensate for the defect promote microstomia, while techniques that bring in additional tissue to compensate for resected lip, either by a pedicled or free flap, are less prone to shrinking the oral opening. In addition, the microstomia may be complicated by radiation therapy.

Although various flap surgeries are described in the literature, converse commissuroplasty is a simple, cheap and less time consuming procedure. In our daily practice we have to be mindful not to compromise function and cosmesis and this technique would be useful in low resource areas for treating microstomia.

References1.Gillies HD, Millard DR. Principles and art of plastic surgery. Boston; Little-Brown; 1957.2.Converse JM. Technique for elongation of the oral fissure and restoration of the angle of the mouth. Kazanjian VH, Converse JM, eds. The surgical treatment of facial injuries. Baltimore; Williams and Wilkins;1959;p. 759.3.Friedlander AH, Zeff S, Sabin H. Cheiloplasty for the correction of microstomia secondary to an untreated burn. J Oral Surg. Jul 1974;32(7):525-7.4.Mehra P, Caiazzo A, Bestgen S. Bilateral oral commissurotomy using buccal mucosa flaps for management of microstomia: report of a case. J Oral Maxillofac Surg. Oct 1998;56(10):1200-3.5.Johns FR, Sandler NA, Ochs MW. The use of a triangular pedicle flap for oral commisuroplasty: report of a case. J Oral Maxillofac Surg. Feb 1998;56(2):228-31.

Dr Rakesh S Ramesh[1], Dr Anusham Anan[2], Dr Suraj Manjunath[1], Dr Tanveer H Ustad[1], Dr Shivakumar K[1][1] Dept of Surgical Oncology, [2] Dept of Plastic and Reconstructive Surgery

St John’s Medical College Hospital, Bangalore, India 560034

 

ConclusionIn India, the majority of patients come from low resource areas and certainly not everybody can afford a free flap reconstruction. Although flap reconstruction is standard of care in some parts of the world, it is not a viable option for most of our Indian patient population. Here we have presented a demonstration of how converse commissuroplasty can be successfully used to treat microstomia; it is a simple, cheap and less time consuming procedure that maintains good function and cosmesis. For a surgeon working in a rural set up without a specialist back up, it can be a particularly useful technique.

Second Primary Carcinoma of the Lip: Surgery and Reconstruction

AimTo describe a simple technique of oral commissure reconstruction called converse commissuroplasty.

Results Patient had an uneventful postoperative period with adequate mouth opening, function and cosmesis.

Commissuroplasty, as performed by Converse (1959). (A) Skin excision designed to accommodate elongation of the commissure. (B) Skin excision performed and mucosal incisions diagrammed. (C) Mucosal flaps incised and mobilized. (D) Mucosal flaps sutured in place. (Reprinted from Converse JM and Wood-Smith D. Techniques for repair of defects of the lips and cheeks. In Converse JM, ed. Reconstructive Plastic Surgery, 2nd edition, volume 3. WB Saunders; Philadelphia:1977. pp.1574, with permission from Elsevier).

Cosmesis

Preoperative

Mouth Opening

Post Operative Day One

Cosmesis Mouth Opening Function

Post Operative Day Seven

Cosmesis Mouth Opening

Post Operative Day Thirty

Cosmesis Mouth Opening Function

Function Muscle Tone