Reconstruction of massive lower lip defect with the composite radial forearm-palmaris longus free flap: Empowered static and partial dynamic reconstruction

Sakai et al described a composite radial forearm plamaris longus flap (CRFPL) for total lower lip reconstruction. However, this technique is not fully capable of preserving satisfactory oral competence, especially when the patients are speaking or eating. Valuable modifications and refinement of the technique of using a composite radial forearm-palmaris longus flap have been described to improve the functional outcomes of this technique. The purpose of this case report is to present a successful empowered static and partial dynamic reconstruction of the massive lower lip defect with the CRFPL. A 70-year-old patient presented with a large tumor of the lower lip with two years of clinical history was referred to our institution. The patient underwent resection of the tumor with bilateral modified neck dissection. The CRFPL flap was harvested from the left forearm at the same time as the tumor resection. The flap was folded over the palmaris longus tendon. We passed the free edges of the palmaris longus tendon through the modiolus bilaterally in appropriate fashion from the subcutaneous plan superficially to the malar en-dnence, following the direction of the zygomaticus major muscle rather than passing them intramuscularly through the modiolus. Afterward, they were anchored to the malar eminences with suitable tension to achieve the empowered sling effect. Postoperative period was uneventful. The follow-up period was one year. There was no local recurrence or regional metastasis. The patient had excellent oral competence both in resting condition and during speaking and eating. Mouth opening was sufficient. He was able to resume a regular diet and had near-normal speech. The aesthetic result was also satisfactory. In conclusion, regardless of the which modification of the reconstruction with CRFPL flap is chosen in such cases, successful reconstruction providing the oral competence and acceptable aesthetic appearance requires the precise pre- and intraoperative planning, respectfulness to the modiolus and suitable placement and anchorage of the palmaris longus tendon into key anatomic points.