PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery 2524 PhiliPPine Journal of otolaryngology-head and neck Surgery PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 ORIGINAL ARTICLES ABSTRACT Objective: To describe our clinical experience with, and functional outcomes of the nasolabial flap for reconstruction of orofacial defects. Methods: Design: Retrospective Case Series Setting: Tertiary National University Hospital Participants: Records of 11 patients on whom a nasolabial flap was performed for reconstruction of head and neck defects between January 2013 and December 2018 were analyzed. Results: All patients underwent wide excision with or without frozen section, with or without neck dissection, and nasolabial flap closure was performed by a single surgeon. There were no major complications. In two cases, the nasolabial flap was used as an adjunct for Abbé and deltopectoral flap reconstruction. One had poor oral competence due to the bulk of the deltopectoral flap. Acceptable aesthetics and functional outcomes were achieved. Conclusion: The nasolabial flap is a viable alternative for reconstruction of orofacial defects following head and neck surgeries. Additional cases can help validate our initial experience. Keywords: Nasolabial flap; nasolabial fold; orofacial defects; oral and facial carcinoma; mouth; skin; surgical flaps With expanded applications of microvascular free tissue transfer techniques for oral cavity reconstruction, the routine need for a variety of local and regional flaps has decreased. However, several such flaps remain quite useful and should be considered as an option for the reconstructive surgeon.1 Among these is the nasolabial flap (NLF), an arterialized local flap in the head and neck region with an axial blood supply provided either by the angular artery branch of the facial artery (inferiorly based) or by the superficial temporal artery through its transverse facial branch and the infraorbital artery (superiorly based). It is a reliable, versatile, and an easy to raise flap for a variety Nasolabial Flap Reconstruction for Orofacial Defects: A Case Series Robert Zaid DLR Diaz, MD Arsenio Claro A. Cabungcal, MD Department of Otolaryngology - Head and Neck Surgery Philippine General Hospital University of the Philippines Manila Correspondence: Dr. Arsenio Claro A. Cabungcal Department of Otolaryngology - Head and Neck Surgery Philippine General Hospital Taft Ave, Ermita, Manila 1000 Philippines Phone: +63 920 921 1081 Email: aacabungcal@up.edu.ph The authors declared that this presents original material that is not being considered for publication or has not been published or accepted for publication elsewhere or in part, in print or electronic media; that the requirements for authorship have been met by both authors, and that the authors believe that the manuscript represents honest work. Disclosures: The authors signed disclosures that there are no financial or other (including personal) relationship, intellectual passion, political or religious beliefs, and institutional affiliations that might led to conflict of interest. Presented at the Philippine Society of Otolaryngology Head and Neck Surgery 1st virtual Descriptive Research Contest (3rd Place) October 21, 2020 Philipp J Otolaryngol Head Neck Surg 2021; 36 (2): 25-29 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc. Creative Commons (CC BY-NC-ND 4.0) Attribution - NonCommercial - NoDerivatives 4.0 International PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery 2726 PhiliPPine Journal of otolaryngology-head and neck Surgery PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 ORIGINAL ARTICLES of small to intermediate defects in the orofacial region. The first NLF for intraoral reconstruction was reported at the end of the 19th century.2 Superiorly-based nasolabial flaps can be used for reconstruction of nasal defects, lower eyelid, and the cheek, whereas the inferiorly based flaps are considered useful in reconstruction of defects of the lip, oral commissure, and the anterior oral cavity.2 A retrospective analysis of 26 cases of oral cancer treated with primary excision and NLF reconstruction concluded that the flap is versatile for covering or reconstructing small or medium-sized defects of the oral cavity in selected patients after excision of primary tumors and results in good overall cosmetic and functional outcome.3 However, to the best of our knowledge, there is a dearth of local publications on reconstruction with this flap. Using the search terms “nasolabial flap” in combination with “facial reconstruction”, “orofacial defects”, “oral” and “facial” defects, a search on PubMed Medline yielded no studies of nasolabial flap from the Philippines. Similar search terms used at HERDIN Plus, the ASEAN Citation Index and the Global Index Medicus yielded four local studies.4-7 We present our five-year clinical experience with nasolabial flaps for orofacial reconstruction and the functional outcomes associated with the use of nasolabial flaps as a primary or an adjunct option for reconstruction of head and neck defects in our institution. METHODS With UPMREB exemption (RGAO-2019-0375), the records of all patients who had undergone NLF reconstruction of head and neck defects under the Department of Otolaryngology - Head and Neck Surgery of the Philippine General Hospital between January 2013 and December 2018 were retrieved for possible inclusion in this case series. Included were records of patients that were staged using TNM classifications, who underwent wide excision with or with frozen section, with or without neck dissection and closure of the defect carried out by the same surgeon (ACAC) under general anesthesia. Incomplete records were excluded. The following data was extracted from the charts and recorded by the first author (RZDD): age, sex, diagnosis, TNM classification, stage, tumor size, tumor location, surgical procedure performed, operative time, and complications. Preoperative contrast enhanced computed tomography and a tissue biopsy were performed in all patients. Radiotherapy was administered for patients who had advanced-stage tumors or adverse features on final histopathology. Surgical Technique Standard inferiorly-based nasolabial flap reconstruction was performed in all cases as follows: following en bloc tumor resection with at least 1.5 cm. margins, a fusiform flap was designed and marked, ensuring that the medial border of the flap was in the nasofacial sulcus. The superior border of the flap was placed inferior to the medial canthus along the nasofacial junction. Placement of the inferior border depended on the nature of the defect. For floor of mouth reconstruction, the inferior border of the flap was at the superior border of the mandible. The skin incision was carried through the dermis and subcutaneous fat up to the layer just above the underlying musculature. The facial artery lay in a plane deep to the facial mimetic musculature and in a medial position along the nasofacial sulcus. The flap was elevated in a superior-to-inferior fashion along a plane just above the facial musculature, and the artery with the facial muscles were preserved at the pedicle inferiorly. The flap was then tunneled through the buccal space to repair an intraoral defect primarily or as an adjunct flap, or placed on defects of the face and lips. The donor site was closed with minimal tension as much as possible using 4‐0 Vicryl sutures for the deep dermal closure and 5-0 fast absorbing catgut sutures to approximate the skin edges. The closure was done in a superomedial direction to avoid distortion of the lower eyelid.8 (Figure 1) Data Analysis Data was presented in simple frequencies and percentages and measures of central tendency of sex (mean and standard deviation) were computed where applicable. Type of surgery, TNM staging, post-operative functional status as well as adjuvant treatment done and follow up period, and the means and standard deviations was presented for continuous data (age). RESULTS A total of 11 patients were included in this series, 7 males and 4 females with a 2:1 ratio of male to female. Their ages ranged from 41 to 75 years old (Mean age 57, SD = 9). The tumor sizes ranged from 8 x 7 mm to 130 x 25 mm. According to histological type and localization of the tumor, American Joint Committee on Cancer (AJCC) TNM classification, four patients were in stage IVa, three in stage III, two in stage II and two in stage I. Hospitalization ranged from 5 days to a maximum of 18 days with average hospital stay of 8.2 days. Final histopathology showed 8 squamous cell carcinomas (SCCA), 1 basal cell carcinoma, 1 adenocarcinoma and 1 leiomyosarcoma. Wide excision of the tumors created defects ranging from the smallest at 18 x 24 mm to the largest at 55 x 65 mm. In 9 cases, a nasolabial flap was used as the primary reconstruction for the defects; PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery 2726 PhiliPPine Journal of otolaryngology-head and neck Surgery PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 ORIGINAL ARTICLES Figure 1.Surgical technique and development of nasolabial flap A. marking and design of the flap along the nasofacial sulcus; B. incision and development of the flap; C. donor site defect; D. tunneling and positioning on the floor of mouth defect; E. suturing and closing of the flap and defect; and F. skin closure. Figure 2. Intraoperative photos of buccal squamous carcinoma A. extent of the mass on the lip commissure with planned wide excision margin; B. lip and buccal defect; C. nasolabial flap after amputation of deltopectoral flap. A B C A D B E C F 8 intraoral (3 buccal, 2 floor of mouth, 2 gingival, and 1 tongue) and 1 upper lip. In two cases, the nasolabial flap was used as an adjunct to another reconstruction flap: an Abbé flap for the lip SCCA and a deltopectoral flap for a through and through buccal SCCA. (Figure 2) Lymphadenopathies were present in 4 of the 11 cases. All those with positive lymph nodes underwent elective neck dissection while 2 lymph node negative cases underwent prophylactic neck dissection. Four stage IVa and three stage III patients underwent radiotherapy as adjuvant treatment. The mean operation time was 6.88 hours, with the fastest at 3 hours and longest at 13 hours. Follow up ranged from 4 to 8 weeks. The complication rate was 18% with 2 flap dehiscences, 1 flap discoloration, and 1 with poor oral competence. There were no other complications like flap loss, total or partial necrosis or infection. The 2 dehiscences PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery 2928 PhiliPPine Journal of otolaryngology-head and neck Surgery PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 ORIGINAL ARTICLES developed after 1 week but these did not progress and resolved through secondary intention healing after around 4 weeks. None of the patients had any complaints about their scars, and were deemed aesthetically acceptable. (Figure 3). Facial movements such as smiling were not affected by the flap. DISCUSSION Our five-year clinical experience with nasolabial flaps for orofacial reconstruction involved 11 patients (eight squamous cell carcinomas and one each basal cell carcinoma, leiomyosarcoma, adenocarcinoma) with tumor sizes ranging 8 x 7 mm to 130 x 25 mm. Post excision defect sizes ranging from 18 x 24 mm to 55 x 65 mm were reconstructed with 9 NLF alone, and 2 NLF in combination with other flaps. The functional outcomes associated with the use of NLF as primary or adjunct option for reconstruction of head and neck defects was satisfactory, with an 18 % complication rate (2 flap dehiscences, 1 flap discoloration, and 1 oral incompetence as the most bothersome complication). Head and neck cancer surgery is often complicated by location, anatomy, complex reconstructions, and long surgical procedures. Reconstruction of head and neck defects may be achieved in a variety of ways.9 Reconstructive options for defects of the orofacial region include primary closure, secondary healing from mucosalization, covering the defect site with split thickness skin grafts, and various pedicled and free flaps. Although reconstruction of orofacial defects using microvascular free flap improves functional and cosmetic outcomes,10 it requires a dedicated team composed of a head and neck surgeon, microvascular surgeon, specialized anesthetist and dedicated nursing and allied medical staff. It also adds more hours to the operating time and even longer hospital stays.11 In low resource areas, pedicled flaps can be the best option. The versatility and usefulness of the nasolabial flap is well established, with good vascular supply that results in higher flap survival.12–14 The vascular supply of the nasolabial flap may come from the anterior facial artery, the infra-orbital artery, the transverse facial artery and the infratrochlear artery (depending on whether it is superiorly or inferiorly based). The nasolabial flap can still be used following extensive neck dissection specially in levels I-III neck dissection. Even if the facial artery is ligated, the flap can be used as random based vascular supply.15 In our present study, all 6 patients who underwent neck dissection did not have any complication of dehiscence or flap failure, supporting the reliability of the nasolabial flap even when neck dissection is performed. The largest defect solely reconstructed with nasolabial flaps was a case of lower lip squamous carcinoma involving 90% of the lower lip for which bilateral nasolabial flaps were used.6 Our current study found the nasolabial flap adequate to cover orofacial defects when used solely, although the extent of our defects was mostly intraoral and the largest defect covered was 60 mm x 60 mm in area. Despite its good reliability and robust vascular supply, the NLF has its limitations. The size of the defect and redundancy of tissues from the defect as well as the possibility of primarily closing the donor site limits the use of the NLF.16 Two cases used nasolabial flap as an adjunct to larger reconstructive option for better coverage. Kallapa and Shah17 reported 24 cases of oral cancers of which 18 were reconstructed with a unilateral nasolabial flap and 3 with a bilateral flap after radical resection. The largest defect size measured 5 x 2 cm and used a 7 x 3 cm unilateral NLF. Three lower lip malignancies were reconstructed with bilateral NLF with the largest defect 6 x 4 cm and reportedly good aesthetic and functional outcomes. Lazaridis et al.18 reported nine patients that underwent reconstruction of intraoral defects with nasolabial flaps, five with an inferiorly based NLF. Speech and oral continence, including mastication, were preserved. Wound healing complications were reported in 18% of our patients, 2 of which were flap dehiscence that eventually resolved thru secondary intention and one with oral incontinence due to the bulk of the deltopectoral flap. Our complication rate is higher than previously reported rates which ranged from 4-11%.15 Figure 3. Post-operative clinical photograph of nasolabial flap donor site PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery 2928 PhiliPPine Journal of otolaryngology-head and neck Surgery PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 36 no. 2 July – december 2021 ORIGINAL ARTICLES REFERENCES 1. Ducic Y, Burye M. Nasolabial flap reconstruction of oral cavity defects: A report of 18 cases. J Oral Maxillofac Surg. 2000 Oct;58(10):1104-1108. DOI:10.1053/joms.2000.9564 PubMed PMID 11021703. 2. Eckardt AM, Kokemüller H, Tavassol F, Gellrich NC. Reconstruction of oral mucosal defects using the nasolabial flap: Clinical experience with 22 patients. Head Neck Oncol. 2011 May 23;3(1):28. DOI:10.1186/1758-3284-3-28. PubMed PMID: 21605443; PubMed Central PMCID: PMC3121716 3. Singh S, Singh RK, Pandey M. Nasolabial flap reconstruction in oral cancer. World J Surg Oncol. 2012 Oct 30;10(1):227. DOI:10.1186/1477-7819-10-227 PubMed PMID: 23110587; PubMed Central PMCID: PMC3544680. 4. Ardena MA, Hawson FY, Guevarra ES. Modified nasolabial flap to the anterior floor of the mouth. Philipp J Otolaryngol Head Neck Surg. 1992;19-22. DOI: https://doi.org/10.32412/pjohns. v35i2.1521. 5. The versatility of the nasolabial flap in nasal reconstruction. Philipp J Otolaryngol Head Neck Surg. 1999; 14(2):31-35. 6. Dy ES, Alfanta EM, Chiong AM. Complications of head and neck reconstructive surgery using axial pedicled flap. Philipp J Otolaryngol Head Neck Surg. 2015; 30 (2): 19-24. DOI: https://doi. org/10.32412/pjohns.v30i2.341. 7. Cordero JC. Reconstruction of large nasal alar squamous cell carcinoma defect using a superiorly - based nasolabial flap. Philipp J Otolaryngol Head Neck Surg 2020; 35 (2): 55-58. DOI: https://doi.org/10.32412/pjohns.v35i2.1521. 8. Wright H, Stephan S, Netterville J. Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery. In: Atlas of Otolaryngology, Head & Neck Operative Surgery. ; 2008:1-12. Available from: www.entdev.uct.ac.za. 9. Copcu E, Metin K, Aktas A, Sivrioglu NS, Öztan Y. Cervicopectoral flap in head and neck cancer surgery. World J Surg Oncol. 2003 Dec;1:1-8. DOI:10.1186/1477-7819-1-29 Pubmed PMID: 14690542; PubMed Central PMCID: PMC317373. 10. Wong CH, Wei F-C. Microsurgical free flap in head and neck reconstruction. Head Neck. 2010 Sep;32(9):1236-45. DOI:10.1002/HED. PubMed PMID: 20014446. 11. Trivedi NP, Trivedi P, Trivedi H, Trivedi S, Trivedi N. Microvascular free flap reconstruction for head and neck cancer in a resource constrained environment in rural India. Indian J Plast Surg. 2013 Jan;46(1):82-6. DOI: 10.4103/0970-0358.113715; PubMed PMID: 23960310; PubMed Central PMCID: PMC3745127. 12. Mitra GV, Bajaj SS, Rajmohan S, Motiwale T. Versatility of modified nasolabial flap in oral and maxillofacial surgery. Arch craniofacial Surg. 2017 Dec;18(4):243-248. DOI:10.7181/ acfs.2017.18.4.243. PubMed PMID: 29349048; PubMed Central PMCID: PMC5759666. 13. Alonso-Rodríguez E, Cebrián-Carretero JL, Morán-Soto MJ, Burgueño-García M. Versatility of nasolabial flaps in oral cavity reconstructions. Med Oral Patol Oral Cir Bucal. 2014 Sep 1;19(5):e525-30. DOI:10.4317/medoral.19376. PubMed PMID: 24880439. 14. Rahpeyma A, Khajehahmadi S. The place of nasolabial flap in orofacial reconstruction: A review. Ann Med Surg. 2016 Nov;12:79-87. DOI:10.1016/j.amsu.2016.11.008. PubMed PMID: 27942380; PubMed Central PMCID: PMC513409. 15. El-Marakby HH, Fouad FA, Ali AH. One stage reconstruction of the floor of the mouth with a subcutaneous pedicled nasolabial flap. J Egypt Natl Canc Inst. 2012 Jun;24(2):71-6. DOI:10.1016/j. jnci.2012.02.002. PubMed PMID: 23582598. 16. Kaluzinski E, Crasson F, Alix T, Labbé D. The nasolabial flap in reconstruction of the columella. Rev Stomatol Chir Maxillofac. 2004 Jun;105(3):171-176. DOI:10.1016/s0035-1768(04)72298-6 PubMed PMID: 15211216. 17. Kallappa S, Shah N. Outcome of nasolabial flap in the reconstruction of head and neck defects. Indian J Surg Oncol. 2019 Dec;10(4):577-581.DOI:10.1007/s13193-019-00948-z. PubMed PMID: 31857747; PubMed Central PMCID: PMC6895328. 18. Lazaridis N, Tilaveridis I, Karakasis D. Superiorly or inferiorly based “islanded” nasolabial flap for buccal mucosa defects reconstruction. J Oral Maxillofac Surg. 2008 Jan;66(1):7-15. DOI:10.1016/j. joms.2006.06.285; PubMed PMID: 18083409. Our study has several limitations. First, our sample size only included 11 patients over five years. We also lack a comparator group. Expanding the use of NLF and comparing it to other reconstructive options based on similar indications (such as tumor stage and histopathology, and defect size) may yield more valuable insights. Moreover, as a single- surgeon experience involving a learning curve, the outcomes and complications may not apply to other surgeons. A more systematic documentation of variables may also provide better quality data for analysis that can be generalized to similar cases beyond the study. Despite these limitations, our initial experience demonstrates that the nasolabial flap is a viable alternative for reconstruction of intraoral and lip defects. Even as other reconstructive options become available, the NLF is useful in resource-challenged settings where microvascular reconstruction is not as accessible.