Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps

Free flaps are generally the preferred method for reconstructing large defe cts of the midface, orbit, and maxilla that include the lip and oral commis sure; commissuroplasty is traditionally performed at a second stage. Functi onal results of the oral sphincter using this reconstructive approach are, however, limited. This article presents a new approach to the reconstructio n of massive defects of the lip and midface using a fr ee flap in combinati on with a lip-switch flap. This was used in 10 patients. One-third to one-h alf of the upper lip was excised in seven patients, one-third of the lower lip was excised in one patient, and both the upper and lower lips were exci sed (one-third each) in two patients. All patients hall maxillectomies, wit h or without mandibulectomies, in addition to full-thickness resections of the cheek. A switch flap from the opposite lip was used for reconstruction of the oral commissure and oral sphincter, and a rectus abdominis myocutane ous flap with two or three skin islands was used tor reconstruction of the through-and-through defect in the midface. Free flap survival was 100 percent. All patients had good-to-excellent oral competence, and they were discharged without feeding tubes. A majority (80 percent) of the patients had an adequate oral stoma and could eat a soft d iet. All patients ha ie a satisfactory postoperative result. Immediate reconstruction of defects using a lip-switch procedure creates an oral sphincter that has excellent function, with good mobility and compete nce. This is a simple procedure that adds minimal operative time to the fle e-flap reconstruction and provides the patient with a functional stoma and acceptable appearance. The free flap can be used to reconstruct the soft ti ssue of the intraoral lining and external skin deficits, but it should not be used to reconstruct the lip.