Letter comments on Patient satisfaction after levator aponeurosis surgery for the treatment of involutional blepharoptosis

Dear Sir, Lower lip and chin reconstruction is challenging for plastic surgeons. Small to medium skin defects on lower face can be removed by staged serial excision or be reconstructed with local flaps 1 or submental artery perforator island flaps. 2 Large skin defects are usually needed by full thickness sheet grafts, tissue expansions or free flaps. 3 However, both skin grafts and free flaps are hindered by the poor skin color and texture match. To achieve the ideal reconstruction of lower lip and chin, expanded cheek flap may be the best choice. However, the potential destruction of facial cosmetic units should also be considered. Here, we present a modified technique for a complete lower lip and chin reconstruction as a whole facial aesthetic unit by using an expanded cheek flap. The study was performed in the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital between March 2011 and November 2015. Six female patients with scars or laser-resistant vascular anomalies on their lower lips and chins underwent reconstruction with this technique. During the first-stage operation, 100-or 200-ml rectangular expanders were implanted underneath the overlying skin on one or both sides of the patients’ cheeks. The expansion began two weeks after the operation. The mean expansion period was three months. Once adequate tissue expansion had been achieved, the second-stage operation was performed. As the lower lip and chin were planned to be reconstructed as a complete facial unit, the shape of the lower lip and chin were copied to a film to serve as a complete template model. The template model was positioned on the expanded cheek skin with a careful presurgical design, and the bottom side of the template model was aligned with the nasolabial fold. Then, the superficial defects of the lower lip and chin were resected and expanded to the border of the complete lower lip and chin unit. The expander was removed. The expanded cheek skin flap was dissected and rotated to the lower lip and chin (Supplemental figure). The flap had a random blood supply. Figure 1 A 20-year-old patient was diagnosed with a port wine stain. She received stick isotropy treatment at another hospital when she was very young. Superficial scars were left on her lower lip, chin and left cheek after that inappropriate treatment. Figure 1 a) One 200-ml rectangular tissue expander was inserted underneath her right cheek. In the second stage, the scars on her lower face were fully removed. The lower lip and chin were reconstructed by using the right expanded cheek flap. No lower lip ectropion was observed. No drooping or microstomia was observed. The scar on the lower lip was rotated from the right expanded cheek flap. The transverse scar beside the right corner of the mouth was created for the "dog-ear" revision ( Figure 1 b). The donor site was subsequently closed using the remaining expanded cheek skin tissue. The incisions were made within the nasolabial fold, vermilion border andmandibular border. Transverse or oblique linear scars on the cheek were created for "dog-ear" revisions in some cases when needed. Drainage was performed for two days after surgery. In our study, three patients had one-cheek skin expansion, and the others had two-cheek skin expansions for defects crossing the lower lip and chin units. All the expanded cheek skin flaps survived, and no major complications were observed. None of the patients had lip ectropion. No drooping or microstomia was observed. There were no obvious deformities at the donor sites. All the patients were satisfied with the results ( Figure 1 ). Many techniques are available for lower lip and chin reconstruction. Local flaps are usually the best option for reconstructing with similar tissue. Modified Karapandzic flaps or extended Karapandzic flaps 4 can reconstruct part or almost all of the lower lip and chin, but some degree of microstomia is inevitable. Therefore, expanded local flaps Correspondence and Communications 1701 with consideration of the facial cosmetic subunits certainly provides a worthwhile option to consider. An expanded neck skin flap may be the mostly used flap for resurfacing the lower lip and chin, 5 but it usually has some drawbacks. Firstly, because of the gravity and the mobility, widen facial scar is common. Secondly, the color of expanded neck is not always matched with the color of face. Thirdly, advancement of the expanded tissue cephalad from the neck to the face carries the risk of lip ectropion either at rest or with neck extension. Plastic surgeons are usually unwilling to use cheek expansion because it may violate facial aesthetic units. To avoid this potential problem, our approach has two key techniques for the reconstruction of the lower lip and chin by using expanded cheek flaps. One technique is that we reconstructed the chin and lower lip as a complete unit. The scars were hidden in vermilion borders, mandibular borders and marionette lines. Another technique is that the cheek scars are designed to be hidden in the nasolabial folds after closing the donor sites. In addition to the invisible scars and insusceptible donor sites, one of the advantages of expanded cheek flaps is the minimal risk of lip ectropion because the flaps are rotated from above without gravitational pull and are not affected by the movement of the neck. Additionally, the texture, colour match, and skin appendages of local tissue from the cheeks remain unparalleled by other donor sites. In conclusion, we think expanded cheek flaps are one choice for reconstructing large, superficial defects of the chin and lower lip and should not be ignored.