Letter to the Editor: Short Report
Pediatric Lip Replantation: A Case of Supermicrosurgical Venous Anastomosis Rachel Rossine Baptista, MD1
Guilherme Cardinali Barreiro, MD1
1 Division of Plastic Surgery, University of São Paulo Medical School,
São Paulo, Brazil 2 Division of Plastic Surgery, Craniofacial Surgery, University of São Paulo Medical School, São Paulo, Brazil
Nivaldo Alonso, MD, PhD2
Address for correspondence Rachel Rossine Baptista, MD, Rua Dr Neto de Araújo, 238, apto 32, São Paulo, São Paulo, Brazil (e-mail: [email protected]).
J Reconstr Microsurg 2015;31:154–156.
Lip replantation is a rare and complex microsurgical procedure.1,2 Establishment of adequate venous outflow following arterial anastomosis is a challenge, especially in pediatric population given the size of the vessels. Leech therapy and scratching techniques under anticoagulation have been employed to improve venous drainage; however, these have the disadvantage of blood loss, scarring, and risk of infection. Here, we describe an upper lip replantation in a 2-year-old child following a dog bite injury using supermicrosurgical techniques for venous drainage.
Case Report A 2-year-old boy sustained total upper lip and partial nose amputation following a Pit Bull dog bite in June 2012 (►Fig. 1). The avulsed flap size was 7 3 cm and included the upper lip with modiolus, lip commissures, left nasal ala, and columella (►Fig. 2). In the operating room, the flap was initially inset through a mucosa-to-mucosa repair. Then under the microscope, the right superior labial artery was identified with 0.8 mm. Following 3 hours of cold ischemia, successful anastomosis was performed with revascularization of the lip. Two 0.3 mm veins, on both sides, were found suitable for anastomosis on the upper lip, and this was performed in an end-to-end fashion using 11–0 nylon suture using supermicrosurgical techniques without vein graft. It was possible to recognize some avulsed nerve fascicles that were positioned in direct contact to the orbicularis oris muscle. Modioli and orbicularis oris continuity restoration were performed. The replanted lip showed satisfactory revascularization and the patient was sent to the pediatric intensive care unit after 6 hours of surgery. The patient had hemoglobin levels of 6.5 gm/dL and received one blood transfusion (10 mL/kg of packed red blood cells). No bleeding or leech therapy was used in the postoperative care.
received May 12, 2014 accepted after revision June 9, 2014 published online July 31, 2014
After 36 hours of the initial surgery, the flap progressively became more congested and the patient was taken back to the operating room for exploration. Under microscopic examination, all vessel anastomoses were patent, but with vasospasm. Local instillation of lidocaine 1% was used. However, because medicinal leech therapy is not available in Brazil, an additional 0.5 mm subcutaneous vein was found and anastomosed to increase drainage and this improved the venous congestion of the flap. The patient was extubated after 5 days. Age and weight adjusted amoxicillin/clavulanate antibiotic was used for 7 days. After 10 days, he was able to feed soft diet by mouth and the feeding tube was removed. There was no infection, partial flap loss, or dehiscence. He was discharged from the hospital after 14 days. At 18 months follow-up, the patient had returned to a normal life. The lip and nose showed a satisfactory esthetic result with excellent contour, shape, and color match. The patient presents sensation recovery, satisfactory static positioning of the lip with a symmetrical smile, and oral competence since postoperative 4 months (►Figs. 3 and 4). He has normal speech and language development for his age.
Discussion Lip defects after traumatic amputations are a challenge to reconstruct with limited esthetic and functional outcomes. Results of lip replantations are superior to lip reconstructive procedures using local tissue rearrangement, and even partial flap loss following a replantation attempt can offer better long-term outcomes.3,4 A review in the English literature showed that 31 cases of lip replantation have been reported so far.1 These descriptive cases differ depending on the age of the patient, the size of the lip segment replanted, the mechanism of injury, the surgical findings, and the postoperative care provided. The upper lip
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1384820. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
154
Baptista et al.
Fig. 3 The lip and nose showed a satisfactory esthetic result with excellent contour, shape, and color match at 18 months follow-up. Fig. 1 Face defect after upper lip amputation and partial nose degloving injury due to dog bite.
was injured in 22 (71%) patients. Lip replantation has been performed in a younger population with a mean age of 24.8 years,1 but only six upper lip replanted cases were performed in pediatric population (►Table 1).3,5–9 A common finding in almost every case reported is that, after re-establishment of arterial inflow, the venous drainage seemed to be most critical and problematic.1,2,6 Overall, only in 13 cases (41.9%) a venous anastomosis could be accomplished, presumably from the inability to find veins in the lip fragment, or in the surrounding facial subcutaneous.1 In pediatric cases, this rate was a little higher, 66%, which may due to bigger amputated fragments in this population, that usually included more facial tissues with the upper lip, and probably carried more proximal and larger caliber veins (►Table 1).
Fig. 2 The avulsed flap with several bite lacerations included the upper lip with modiolus, lip commissures, left nasal ala, and columella.
Leeches or alternative bleeding techniques such as scratching with systemic anticoagulation were used to treat inadequate venous outflow. Daraei et al reported 24 (77.4%) lip replanted cases required leech therapy for venous congestion.1 In pediatric population, 50% needed leeches therapy (►Table 1). The disadvantages of these methods include blood loss, infection, and scarring. To date, there have been several detailed investigations on labial arterial anatomy. However, fewer studies have delineated labial venous drainage, despite its major concern in lip
Fig. 4 Orbicularis oris functional recovery after upper lip replantation.
Journal of Reconstructive Microsurgery
Vol. 31
No. 2/2015
155
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Pediatric Lip Replantation
No 2 Yes
5
This case report of a successful pediatric upper lip replantation illustrates the critical importance of understanding venous drainage in the face and the use of supermicrosurgical techniques for venous anastomosis.
No
References
1
1 Daraei P, Calligas JP, Katz E, Etra JW, Sethna AB. Reconstruction of
1
1
1a
Upper and lower lip 6 2014 DeLeon et al
Upper and lower lip 7 2013 de la ParraMárquez et al
Lateral upper lip 7 2012 Hendrick and Tiwari
5 6
a
6
5
4
7
Arterialized venous anastomosis.
1 Central Upper lip 17 2009 3
Taylor and Andrews
2 Upper lip, nose, and left cheek 3.5 2
Tschopp
1981
1 Upper lip and nose 3 1976 1
James
Age (y) Author No.
Journal of Reconstructive Microsurgery
3 4
Year
Part
Artery
2
Vol. 31
No. 2/2015
8
9
10
upper lip avulsion after dog bite: case report and review of literature. Am J Otolaryngol 2014;35(2):219–225 Walton RL, Beahm EK, Brown RE, et al. Microsurgical replantation of the lip: a multi-institutional experience. Plast Reconstr Surg 1998;102(2):358–368 James NJ. Survival of large replanted segment of upper lip and nose. Case report. Plast Reconstr Surg 1976;58(5):623–625 Höltje WJ. Successful replantation of an amputated upper lip. Plast Reconstr Surg 1984;73(4):664–670 Tschopp HM. Reconstructive surgery after severe animal bite injuries of the head and neck area. Chirurgia Plastica 1983;7(2):89–102 Taylor HO, Andrews B. Lip replantation and delayed inset after a dog bite: a case report and literature review. Microsurgery 2009; 29(8):657–661 Hendrick RG Jr, Tiwari P. Successful replantation of upper lip avulsion injury using an arterialized venous anastomosis. Plast Reconstr Surg 2012;130(4):628e–629e DeLeon AN, Rinard JR, Mahabir RC. Successful replantation of a portion of the upper and lower lip with the oral commissure. Ann Plast Surg 2014;72(1):3–4 de la Parra-Márquez M, Mondragón-González S, López-Palazuelos J, Naal-Mendoza N, Rangel-Flores JM. Face replantation using labial artery for revascularization. Case report [in Spanish]. Cir Cir 2013; 81(3):221–224 Taylor GI, Caddy CM, Watterson PA, Crock JG. The venous territories (venosomes) of the human body: experimental study and clinical implications. Plast Reconstr Surg 1990;86(2):185–213
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Good Good Survived
No Not related No No 1
8 Yes 0
No
7 No 0
No Yes 2
No No 1
Yes
Conclusion
Duration (d) Leech use Vein graft Vein
replantation. Anatomical descriptions have reported that the facial vein has a straight course and is located lateral to the facial artery. Furthermore, the venous territories illustrated by Taylor and Andrews10 demonstrated that the venous drainage of the upper lip has a superior course before draining into the facial vein, lateral to nasal alar base in the infraorbital area. This anatomical information is clinically important to find veins in cases of upper lip replantation. Efficient venous outflow helps diminish excessive postoperatory flap edema and the need for leech or scratch anticoagulation therapies. Following the establishment of a viable replanted upper lip, the functional and esthetic outcome will depend on the motor and sensory recovery. Proper lip muscles positioning and continuity restoration is important to achieve normal lip excursion. Previously reported cases have presented satisfactory functional recovery without nerve repair, attributed to direct neurotization. Successful replantation of highly specialized face tissues offers far superior reconstructive outcomes and opens a new paradigm in the face reconstruction. After immune tolerance in vascularized composite allotransplantation becomes a reality, these defects could be reconstructed with subunit face allotransplantation, instead of conventional staged techniques, with better functional and esthetic outcomes.
No
Good Good Survived
Yes 10
Yes, systemic
Not related Good Survived
Yes 10
Yes, systemic
Good Good Survived
Yes 2
Yes, topical
Good Good Survived
No Not related
No
Not related Not related Partial loss
Chemical Leeching
Yes, systemic
Baptista et al.
Blood units
Anticoagulation
Outcome
Motor function
Sensitive recovery
Pediatric Lip Replantation
Table 1 Pediatric upper lip replantation
156
Copyright of Journal of Reconstructive Microsurgery is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Pediatric Lip Replantation: A Case of Supermicrosurgical Venous Anastomosis Rachel Rossine Baptista, MD1
Guilherme Cardinali Barreiro, MD1
1 Division of Plastic Surgery, University of São Paulo Medical School,
São Paulo, Brazil 2 Division of Plastic Surgery, Craniofacial Surgery, University of São Paulo Medical School, São Paulo, Brazil
Nivaldo Alonso, MD, PhD2
Address for correspondence Rachel Rossine Baptista, MD, Rua Dr Neto de Araújo, 238, apto 32, São Paulo, São Paulo, Brazil (e-mail: [email protected]).
J Reconstr Microsurg 2015;31:154–156.
Lip replantation is a rare and complex microsurgical procedure.1,2 Establishment of adequate venous outflow following arterial anastomosis is a challenge, especially in pediatric population given the size of the vessels. Leech therapy and scratching techniques under anticoagulation have been employed to improve venous drainage; however, these have the disadvantage of blood loss, scarring, and risk of infection. Here, we describe an upper lip replantation in a 2-year-old child following a dog bite injury using supermicrosurgical techniques for venous drainage.
Case Report A 2-year-old boy sustained total upper lip and partial nose amputation following a Pit Bull dog bite in June 2012 (►Fig. 1). The avulsed flap size was 7 3 cm and included the upper lip with modiolus, lip commissures, left nasal ala, and columella (►Fig. 2). In the operating room, the flap was initially inset through a mucosa-to-mucosa repair. Then under the microscope, the right superior labial artery was identified with 0.8 mm. Following 3 hours of cold ischemia, successful anastomosis was performed with revascularization of the lip. Two 0.3 mm veins, on both sides, were found suitable for anastomosis on the upper lip, and this was performed in an end-to-end fashion using 11–0 nylon suture using supermicrosurgical techniques without vein graft. It was possible to recognize some avulsed nerve fascicles that were positioned in direct contact to the orbicularis oris muscle. Modioli and orbicularis oris continuity restoration were performed. The replanted lip showed satisfactory revascularization and the patient was sent to the pediatric intensive care unit after 6 hours of surgery. The patient had hemoglobin levels of 6.5 gm/dL and received one blood transfusion (10 mL/kg of packed red blood cells). No bleeding or leech therapy was used in the postoperative care.
received May 12, 2014 accepted after revision June 9, 2014 published online July 31, 2014
After 36 hours of the initial surgery, the flap progressively became more congested and the patient was taken back to the operating room for exploration. Under microscopic examination, all vessel anastomoses were patent, but with vasospasm. Local instillation of lidocaine 1% was used. However, because medicinal leech therapy is not available in Brazil, an additional 0.5 mm subcutaneous vein was found and anastomosed to increase drainage and this improved the venous congestion of the flap. The patient was extubated after 5 days. Age and weight adjusted amoxicillin/clavulanate antibiotic was used for 7 days. After 10 days, he was able to feed soft diet by mouth and the feeding tube was removed. There was no infection, partial flap loss, or dehiscence. He was discharged from the hospital after 14 days. At 18 months follow-up, the patient had returned to a normal life. The lip and nose showed a satisfactory esthetic result with excellent contour, shape, and color match. The patient presents sensation recovery, satisfactory static positioning of the lip with a symmetrical smile, and oral competence since postoperative 4 months (►Figs. 3 and 4). He has normal speech and language development for his age.
Discussion Lip defects after traumatic amputations are a challenge to reconstruct with limited esthetic and functional outcomes. Results of lip replantations are superior to lip reconstructive procedures using local tissue rearrangement, and even partial flap loss following a replantation attempt can offer better long-term outcomes.3,4 A review in the English literature showed that 31 cases of lip replantation have been reported so far.1 These descriptive cases differ depending on the age of the patient, the size of the lip segment replanted, the mechanism of injury, the surgical findings, and the postoperative care provided. The upper lip
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1384820. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
154
Baptista et al.
Fig. 3 The lip and nose showed a satisfactory esthetic result with excellent contour, shape, and color match at 18 months follow-up. Fig. 1 Face defect after upper lip amputation and partial nose degloving injury due to dog bite.
was injured in 22 (71%) patients. Lip replantation has been performed in a younger population with a mean age of 24.8 years,1 but only six upper lip replanted cases were performed in pediatric population (►Table 1).3,5–9 A common finding in almost every case reported is that, after re-establishment of arterial inflow, the venous drainage seemed to be most critical and problematic.1,2,6 Overall, only in 13 cases (41.9%) a venous anastomosis could be accomplished, presumably from the inability to find veins in the lip fragment, or in the surrounding facial subcutaneous.1 In pediatric cases, this rate was a little higher, 66%, which may due to bigger amputated fragments in this population, that usually included more facial tissues with the upper lip, and probably carried more proximal and larger caliber veins (►Table 1).
Fig. 2 The avulsed flap with several bite lacerations included the upper lip with modiolus, lip commissures, left nasal ala, and columella.
Leeches or alternative bleeding techniques such as scratching with systemic anticoagulation were used to treat inadequate venous outflow. Daraei et al reported 24 (77.4%) lip replanted cases required leech therapy for venous congestion.1 In pediatric population, 50% needed leeches therapy (►Table 1). The disadvantages of these methods include blood loss, infection, and scarring. To date, there have been several detailed investigations on labial arterial anatomy. However, fewer studies have delineated labial venous drainage, despite its major concern in lip
Fig. 4 Orbicularis oris functional recovery after upper lip replantation.
Journal of Reconstructive Microsurgery
Vol. 31
No. 2/2015
155
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Pediatric Lip Replantation
No 2 Yes
5
This case report of a successful pediatric upper lip replantation illustrates the critical importance of understanding venous drainage in the face and the use of supermicrosurgical techniques for venous anastomosis.
No
References
1
1 Daraei P, Calligas JP, Katz E, Etra JW, Sethna AB. Reconstruction of
1
1
1a
Upper and lower lip 6 2014 DeLeon et al
Upper and lower lip 7 2013 de la ParraMárquez et al
Lateral upper lip 7 2012 Hendrick and Tiwari
5 6
a
6
5
4
7
Arterialized venous anastomosis.
1 Central Upper lip 17 2009 3
Taylor and Andrews
2 Upper lip, nose, and left cheek 3.5 2
Tschopp
1981
1 Upper lip and nose 3 1976 1
James
Age (y) Author No.
Journal of Reconstructive Microsurgery
3 4
Year
Part
Artery
2
Vol. 31
No. 2/2015
8
9
10
upper lip avulsion after dog bite: case report and review of literature. Am J Otolaryngol 2014;35(2):219–225 Walton RL, Beahm EK, Brown RE, et al. Microsurgical replantation of the lip: a multi-institutional experience. Plast Reconstr Surg 1998;102(2):358–368 James NJ. Survival of large replanted segment of upper lip and nose. Case report. Plast Reconstr Surg 1976;58(5):623–625 Höltje WJ. Successful replantation of an amputated upper lip. Plast Reconstr Surg 1984;73(4):664–670 Tschopp HM. Reconstructive surgery after severe animal bite injuries of the head and neck area. Chirurgia Plastica 1983;7(2):89–102 Taylor HO, Andrews B. Lip replantation and delayed inset after a dog bite: a case report and literature review. Microsurgery 2009; 29(8):657–661 Hendrick RG Jr, Tiwari P. Successful replantation of upper lip avulsion injury using an arterialized venous anastomosis. Plast Reconstr Surg 2012;130(4):628e–629e DeLeon AN, Rinard JR, Mahabir RC. Successful replantation of a portion of the upper and lower lip with the oral commissure. Ann Plast Surg 2014;72(1):3–4 de la Parra-Márquez M, Mondragón-González S, López-Palazuelos J, Naal-Mendoza N, Rangel-Flores JM. Face replantation using labial artery for revascularization. Case report [in Spanish]. Cir Cir 2013; 81(3):221–224 Taylor GI, Caddy CM, Watterson PA, Crock JG. The venous territories (venosomes) of the human body: experimental study and clinical implications. Plast Reconstr Surg 1990;86(2):185–213
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Good Good Survived
No Not related No No 1
8 Yes 0
No
7 No 0
No Yes 2
No No 1
Yes
Conclusion
Duration (d) Leech use Vein graft Vein
replantation. Anatomical descriptions have reported that the facial vein has a straight course and is located lateral to the facial artery. Furthermore, the venous territories illustrated by Taylor and Andrews10 demonstrated that the venous drainage of the upper lip has a superior course before draining into the facial vein, lateral to nasal alar base in the infraorbital area. This anatomical information is clinically important to find veins in cases of upper lip replantation. Efficient venous outflow helps diminish excessive postoperatory flap edema and the need for leech or scratch anticoagulation therapies. Following the establishment of a viable replanted upper lip, the functional and esthetic outcome will depend on the motor and sensory recovery. Proper lip muscles positioning and continuity restoration is important to achieve normal lip excursion. Previously reported cases have presented satisfactory functional recovery without nerve repair, attributed to direct neurotization. Successful replantation of highly specialized face tissues offers far superior reconstructive outcomes and opens a new paradigm in the face reconstruction. After immune tolerance in vascularized composite allotransplantation becomes a reality, these defects could be reconstructed with subunit face allotransplantation, instead of conventional staged techniques, with better functional and esthetic outcomes.
No
Good Good Survived
Yes 10
Yes, systemic
Not related Good Survived
Yes 10
Yes, systemic
Good Good Survived
Yes 2
Yes, topical
Good Good Survived
No Not related
No
Not related Not related Partial loss
Chemical Leeching
Yes, systemic
Baptista et al.
Blood units
Anticoagulation
Outcome
Motor function
Sensitive recovery
Pediatric Lip Replantation
Table 1 Pediatric upper lip replantation
156
Copyright of Journal of Reconstructive Microsurgery is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
