'AJ's Orbicularis Oris Stitch: A Novel and Simple Technique of Reconstructing Central Arch Mandibular Defects in Resource-Constrained Set Up'

Abstract

Lip and oral cavity SCC account for 2nd highest incidence of cancers and 3rd most common cause of mortality from cancer in India. Reconstruction of defects of central arch invading cancers results in poor cosmetic and functional outcomes if free flaps are not used. 30 patients with Oral SCC in the age group 20-75 years requiring central arch segmental mandibulectomy were included. Reconstruction was done with pedicled bipaddled PMMC flap with 'AJ's orbicularis oris stitch' using Fiber wire. Patients were divided into 4 groups according to extent of lip and skin loss post excision of primary tumour. Patients were evaluated with subjective scores for drooling, oral competence and cosmesis. There were 4, 12, 9 and 5 patients in Group A, B, C and D respectively. Mean subjective scores using our technique for drooling, oral competence and cosmesis were 3.75/4,3.75/4 and 3.5/4 for group A, 3.45/4, 3.36/4 and 3.09/4 for group B, 2.8/4, 2.6/4 and 2.3/4 for group C defects and 2.5/4, 3/4 and 2.5/4 for group D defects respectively. Over all scores for all patients were 3.2/4, 3.14/4 and 2.84/4 for drooling, oral competence and cosmesis. This simple, quick and inexpensive technique of reconstruction of central mandibular arch defects can drastically improve cosmetic and functional outcomes in a resource restrained set up. However, long term results and comparison studies are required for standardisation of the technique.

Keywords: Central arch; Fiber wire; Orbicularis oris; Pectoralis major myocutaneous flap; Squamous cell carcinomas.

Fig. 1

Technique of AJ’s Stitch

Fig. 2

Group A defect with segmental mandibulectomy with no skin and lip loss. Reconstruction with Outer paddle of bilobed PMMC de-epithealised and fiber wire

Fig. 3

Group B defects with segmental mandibulectomy with no lip loss but skin loss. Bipaddled PMMC reconstruction with fiber wire. Flap de-epithealised along lower lip. a–c Patient with Group B large defect. e–f Patient with Group B small defect

Fig. 4

Group C defects with segmental mandibulectomy with partial lip loss and skin loss. Reconstruction done with bi-paddled PMMC with de-epithealisation corresponding to lip and Fiber wire. a–d Patient was newly diagnosed diabetic with uncontrolled sugars and had minor SSI which was managed conservatively. e–f Another patient with similar defect

Fig. 5

Group D defects with segmental mandibulectomy and complete lip and skin loss. a–c Patient with severe malnutrition with BMI 15 and weight 30 kg, had superficial flap loss which was managed conservatively. d–e Another patient with similar defect. f Intra-operative photograph of another patient after reconstruction