Abbreviations:

BFP: Buccal Fat Pad; FFG: Free Fat Graft; PBFPF: Pedicle Buccal Fat Pad Flap; BFFG: Buccal Free Fat Graft

1. Introduction

The lips are crucial in phonetics, facial esthetics, and facial expression. Squamous cell carcinoma (SCC) is the most common malignancy affecting the lower lip. 90% of all lip SCCs involve the lower lip, which has been shown to be exposed to higher doses of UV radiation from sunlight than the upper lip [1]. However, labial defects resulting from tumor resection can severely impair patients’ quality of life [2]. Several reconstruction techniques have been reported in the literature with extensive lip defects necessitating complex methods to restore lip anatomy and volume [3-5].

The buccal fat pad (BFP), first described by Bichat, is considered a multipurpose graft for intraoral soft tissue defects. Reports emerged on using the BFP as a pedicled and free graft [6,7]. However, the Pedicle fat pad graft (PBFPF) use for lip reconstruction has yet to be documented. Herein, we report a case in which an SCC-affected lip was reconstructed using a free buccal fat pad graft(BFFG).

2. Case Report

A 64 old male was admitted to the oral and maxillofacial surgery department. His medical history included diabetes mellitus and hypertension, with a history of heavy smoking. The patient admitted to our department with a painful indurated exophytic lesion over the dry vermilion, with skin involvement and leukoplakia (Figure 1). The patient underwent an incisional biopsy with no post-operative complications (Figure 2), and a moderate to poorly differentiated squamous cell carcinoma with invasion of skin tissue was diagnosed. Subsequent imaging ruled out lymph node involvement. The patient was informed of the diagnosis, the proposed surgical procedure, including harvesting of the BFFG and subsequent lip reconstruction, and possible complications associated with the process. Under general anesthesia with nasal intubation, after marking the tumor borders, a vermilionectomy and a wide V-shaped resection of the tumor with 1.0 cm margins were performed (Figure 3). Pathological examination (frozen sections) performed during the surgery verified that the surgical margins were tumor-free. Once the lesions was removed, the reconstruction included a mucosal advancement flap and undermining of the adjacent skin and mucosal edges, with bilateral dissection of the Orbicularis Oris muscle to allow re-approximation during wound closure. (Figure 3). A BFFG was harvested from the maxillary vestibule using blunt dissection and transferred as a free graft to add volume after the resection (Figure 4). The advancement flap was released and sutured to adjacent skin using resorbable sutures (Ethicon, NJ, USA) (Figure 4). The BFFG was adapted to the surgical bed, followed by re-approximation of residual lip margins (Figure 5).

Post-operatively, the patient was maintained on a soft diet. The patient had no complications during follow-ups at one, four, eight, and 24-weeks post-operatively. Both functional and aesthetic outcomes were satisfactory, with normal lip function and sensation, mouth opening of 45 mm, good color and texture, and excellent volume at the grafted site (Figure 6). The patient did not report any discomfort, and no subsequent surgeries were required 12 months after the initial surgery.

Figure 1: Color image of the initial lower lip lesion. The patient presented with an indurated exophytic lesion over the dry vermilion, exhibiting both skin involvement and leukoplakia of the vermilion.

Figure 2: Color image of excisional biopsy site. An excisional biopsy was performed including uninvolved skin tissue outside of the lesion boundaries.

Figure 3: Resection of the tumor. According to histopathological diagnosis of SCC, a resection of the tumor was performed with 1.0 cm margins (A, B). Following the resection, undermining of the adjacent skin and mucosal edges was performed together with dissection of the orbicularis oris muscle (C).

Figure 4: Lip reconstruction utilizing the BFFG harvested from the right BFP (A). After the advancement flap was released and advanced towered the skin, the BFFG was secured within the surgical bed (B).

Figure 5: Closure of the reconstructed site. Residual lip tissue margins were re-approximated of, allowing tension-free closure.

Figure 6: Follow-up examination 12 months after the reconstruction. Functional and aesthetic outcomes were satisfactory with adequate mouth opening of 45mm (A). The grafted site exhibited good color and texture of that matched adjacent tissues, with satisfactory lower lip volume (B).

3. Discussion

Reconstruction of lip defects resulting from tumor ablative surgery is challenging, especially when the defect is larger than one-third of the lip size [8]. Achievement of complete and adequate lip defects closure necessitates using tension-free margins and grafts with sufficient volume and thickness. Several surgical techniques employing local and regional grafts and flaps have been proposed for lower lip reconstruction [1,2,5,9], such as the rotational fan flap [10], pedicled flaps utilizing the facial [5,11] or labial [12] vasculature. However, these flaps may result in perioral scars and microstomia [8,13-15], and donor site morbidity [16].

The free BFFG has been described as a graft able to support the reconstruction of soft tissue defects in the oral cavity [6]. These include intraoral defects in the hard palate, oral mucosa, and the alveolar ridges [7,17,18] as well as the reconstruction of major oral defects [19-22]. The ease of harvest, handling, and minimal donor-site morbidity of the BFFG enhances defect healing and rapid epithelialization [23,24]. The use of adipose grafts has been recently shown to possess major biological advantages, such as promoting soft tissue repair through neovascularization or migration of support cells from the graft into the engraftment site [25,26]. Moreover, the therapeutic potential of stem cells residing in adipose tissue has also been shown in previous reports, supporting the use of adipose tissue as a biological initiator of tissue remodeling and repair, both in pre-clinical and clinical studies [27-30].

Kim and Sasidaran reported on the free BFFG for soft tissue augmentation in the facial region with excellent outcomes. They stated that this graft is an effective option as a volumizer for filling defects in the head and neck area [31]. Recently, the BFFG has been utilized for aesthetic filling in complex maxillofacial cases following facial deformity-related reconstruction, post-traumatic surgical correction, and facial augmentation after tumor ablation [32,33].

Herein, we report for the first time a successful lower lip reconstruction utilizing the BFFG in a patient with lower lip deficiency secondary to resection of a malignant tumor. The fat graft compensated the resected volume and enhanced the closure of the surgical site. Adequate mouth closure and opening without microstomia and a natural contour of the reconstructed lower lip were obtained, providing acceptable aesthetic and functional results without extensive harvest of autologous tissue. The intra-oral donor site of the BFPG underwent complete healing, with no post-operative complications or visible scars.

4. Summary

The technique described in the current case may provide a simple and reliable tool for lower lip reconstruction, achieving aesthetic lower lip rehabilitation in a single stage with minimal scarring and morbidity.

Author contributions

Conceptualization, Surgeries and follow-up: F.K; writing, F.K et al; Review&editing: F.K ,I.R, S.S

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