Stein's Double Cross-Lip Flaps Combined with Johanson's Step Technique for Subtotal Lower Lip Reconstruction

Abstract

In a previous study, a single cross-lip flap (Abbe flap) combined with Johanson's step technique for repair of defects of more than 2/3 of the lower lip was superior, in terms of aesthetic and functional outcome, compared with Bernard Webster-related techniques (cheek advancement). Herewith, a double cross-lip flap (Stein procedure) is proposed for repair of subtotal lower lip defects. A systematic review of the Stein procedure is provided.

Methods: Two patients underwent a paramedian double cross-lip flap, preserving the aesthetic subunit philtrum column combined with the Johanson's step technique. The aesthetic and functional outcomes and the surgical steps are demonstrated in the videos. An electromyographic study was performed 6 months and 4 years after surgery. A PubMed and a Google Scholar search were performed for the Stein procedure published in 1848.

Results: Lip competence was achieved directly after sectioning of the cross-lip pedicles in both patients. Lips progressivity expanded in the first 6 months. No microstomia was observed. Electromyography showed successful reinnervation of the transplanted muscles at 6 months. Four years after surgery, the electromyographic findings were consolidated. Since 1975, 7 articles on the double cross-lip procedure have been published: 4 in English, 1 in French, and 2 in Japanese. None of those articles reported on any supplemental lower lip advancement or on any electromyographic study.

Conclusions: The rationale of using 2 cross-lip flaps and a lip-cheek advancement according to Johanson seems to achieve functionally and aesthetically superior results compared with other techniques described for subtotal lower lip reconstruction.

Fig. 1.

Sixty-one-year-old man presented with an ulcerated carcinoma of the lower lip with involvement of the left commissure (A and C). The profile view is an important preoperative record to evaluate the postoperative result (B). Double cross-lip flap combined with the Johanson’s step technique immediately after subtotal lower lip resection (D, E). The surgical procedure is presented step by step in Video 1 (Supplemental Digital Content 1, which demonstrates a subtotal lower lip resection and reconstruction by means of Stein’s double cross-lip flaps and a Johansons’s step technique. This is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A165 and see description under Refinements of the Stein Procedure).

Fig. 2.

Postoperative result 6 months after subtotal lower lip resection and reconstruction by means of double cross-lip flaps and a Johansons’s step technique (A,C) (preoperative photographs in Fig. 1). Markings show area of placement of concentric needle electrodes for electromyographic (EMG) assessment of the upper lip as donor site and for the lower lip as receptor site. The EMG (B) shows motor unit action potentials (MUAPs) of normal size but with an increased polyphasicity and (D) normal recruitment of many motor units.

Fig. 3.

Postoperative result 4 years after subtotal lower lip resection and reconstruction by means of double cross-lip flaps and a Johansons’s step technique (preoperative photographs in Fig. 1). The mimic is almost not altered (A); upper and lower lip expansion is clearly appreciated when compared with the immediate result after surgery, whereas the upper and lower lip length is equal (Fig. 1D). The profile view (B) shows an unaltered lip high and harmonious anterior–posterior relation to the upper lip. Mouth opening is unrestricted (D). On pouting, a nearly normal muscular activity is appreciated (D).

Fig. 4.

Eighty-one-year-old man presented with an ulcerated basal cell carcinoma of the lower lip localized right sided between the vermilion border and the labiomental fold located on a childhood irradiated hemangioma (A–C). Double cross lip-flap switched into the lower lip and tailored into the rectangular defect preserving the labiomental fold (D–E).

Fig. 5.

Postoperative result 1 year after subtotal lower lip resection and reconstruction by means of double cross-lip flaps and a Johansons’s step technique (preoperative photographs in Fig. 4). The facial expression is unchanged (A). In profile, the lower lip high is unchanged (B). Mouth opening is unrestricted (C). The aesthetic units of the face are well preserved (the caudal view, D). Wearing of a dental prosthesis is unrestricted (D).

Video 1.

A subtotal lower lip resection and reconstruction by means of Stein’s double cross-lip flaps and a Johansons’s step technique. A 4-year follow-up and an electromyographic assessment are provided (case 1, Figs. 1–3), see under Refinements of the Stein Procedure for detailed description step by step. This is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A165.

Video 2.

A 1-year follow-up after subtotal lower lip resection and reconstruction by means of Stein’s double cross-lip flaps and a Johansons’s step technique (Case 2, Figs. 4 and 5), see under Refinements of the Stein Procedure for detailed description step by step. This is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A166.