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Table of Contents
Year : 2021  |  Volume : 29  |  Issue : 3  |  Page : 186-189

Single flap use for synchronous reconstruction of full-thickness upper and lower lip defects due to high-voltage electrical burn

Department of Plastic Reconstructive and Aesthetic Surgery, Kocaeli University, Izmit, Kocaeli, Turkey

Date of Submission08-Sep-2020
Date of Acceptance05-Dec-2020
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Emrah Kagan Yasar
Department of Plastic, Reconstructive and Aesthetic Surgery, School of Medicine, Kocaeli University, Kocaeli
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_98_20

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High-voltage electric burns are a major source of morbidity and mortality, with significant socioeconomic and psychosocial implications. Electric burns rarely cause injury to atypical areas including the oral region with a reported incidence of 2.2%–3.5%. The ratio of burn area to total lip is critical for reconstruction options. Locally usable flap choices will be insufficient for subtotal defects of lips. Electrical burn of both lips is a rarely seen entity that is surgically challenging for both lip reconstruction with the minimum morbidity. It is known that a radial forearm free flap (RFFF) is suitable for total lip reconstruction and in addition, is one of the best options for simultaneous upper and lower lip reconstruction using only one RFFF. In this study, a case with both lower and upper lib necrosis, a rarely affected area due to high-voltage electrical burn, is presented. Reconstruction with a free radial forearm flap was successfully performed although the patient was presented in the subacute period as timing.

Keywords: Burn, radial forearm, total lips reconstruction

How to cite this article:
Yasar EK, Demir CI, Kaya S, Alagoz MS. Single flap use for synchronous reconstruction of full-thickness upper and lower lip defects due to high-voltage electrical burn. Turk J Plast Surg 2021;29:186-9

How to cite this URL:
Yasar EK, Demir CI, Kaya S, Alagoz MS. Single flap use for synchronous reconstruction of full-thickness upper and lower lip defects due to high-voltage electrical burn. Turk J Plast Surg [serial online] 2021 [cited 2021 Sep 17];29:186-9. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/3/186/322678

  Introduction Top

Electric injuries comprise between 3% and 32.2%[1],[2] of total admissions to burn centers in different countries of the world. Classification of electrical injuries is arbitrarily divided into low voltage, which is lower than 1000 V, and high-voltage which is higher than 1000 V.[3] The majority of high and low voltage injuries in adults, however, are related to occupation and a male predominance is found.[4] These injuries are a major source of morbidity and mortality, with significant socioeconomic implications, especially in high-voltage electric burn patients. Mortality for high-voltage injury in a study by Arnoldo et al. was 5.3%.[3] Mortality for high-voltage injuries varies in other studies from 0% reported by Rai et al.,[4] in the high-voltage subgroup of their pediatric series, to 21.7% in a mixed population reported by Acosta et al.[2]

As the voltage increases, soft-tissue destruction will increase proportionally, and large defects can occur in high-energy electrical burns, leading to the risk of compartment syndrome in the upper extremities and bone exposures in the lower limbs. Therefore, high-voltage injuries are potentially most debilitating because they are more often associated with deep muscle necrosis, the need for fasciotomy, and amputation.[3]

Electric burns can rarely cause injury to atypical areas. The reported incidence of oral burns range from 2.2% to 3.5%.[5],[6] The aim of this report was to describe the reconstruction process and outcome of a patient with full-thickness burn necrosis due to a high-energy electrical burn, in an atypical area almost totally limited to the upper and lower lips.

  Surgıcal Technique Top

A 26-year-old male patient, who was working as an electrician, presented at our clinic because of full-thickness burns on both lips. The patient history revealed exposure to a high-energy electric current in the workplace 6 days previously. Initial consultation had taken place at an outer medical center. The patient had no comorbidities and he was not using any medication, other than the drugs prescribed for the treatment of this full thickness burn which were amoxicillin-clavulanic acid 2 × 1000 mg and dexketoprofen 1 mg × 25 mg. All drugs were stopped after hospitalization and therapy was continued intravenously.

On physical examination, the full-thickness burned areas started from 1.5 cm medial of the right commissure in the oral region of the patient, extending from skin to mucosa. There was necrosis of both lips at the left commissure with full-fold necrosis up to the gingivobuccal sulcus, including the mucous membrane on both lips. While the highest affected area on the upper lip was adjacent to the left nasal alar base, the deepest affected area on the lower lip was in the neighborhood of the outlet of the right mental nerve. The measurements of the affected areas were approximately 6.0 cm × 2.5 cm size defects on the upper lip skin and 6.5 cm × 3.5 cm size defects on the lower lip with accompanying full-thickness mucosa burn. It was evident that the right oral commissure was preserved, but the left oral commissure was completely affected, as shown in [Figure 1].
Figure 1: A 26-year-old electrician had totally necrotic tissue on both the lower and upper lip (Left). After debridement, it is seen that the skin and mucosa were simultaneously affected with similar percentages and the right commissure was intact. The percentage of the defect was approximately 90% for both lips (Center). Eleven months after reconstruction, an acceptable appearance of face was evident, and results for neurosensorial tests were also good (Right)

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The patient was recommended to undergo reconstruction with fasciocutaneous radial forearm free flap (RFFF), which is a suitable source for lip reconstruction with a single-stage reconstruction using free flap. Allen tests were performed on both forearms and ulnar artery dominance was observed bilaterally. In the preoperative period, double skin island, neurosensitive RFFF with palmaris longus tendon was roughly schematized and the planning process was completed. The nondominant side forearm had some burned surface area on the ulnar volar side, which was not a problem for RFFF planning and harvesting [Figure 2].
Figure 2: Left radial forearm was prepared for free flap harvesting and two skin island markings are shown (Left). After flap harvesting, the neurovascular pedicles are marked (Right) (Red a: Radial artery, two small v: concomitant veins, yellow n: lateral antebrachial cutaneous nerve, CV: cephalic vein)

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Swab cultures were taken from the hospitalized patient and 4 g × 1 g intravenous cefazolin was started as empirical treatment. The operation was started under general anesthesia by nasal intubation and worked in the supine position. After all necrotic areas were debrided; the right mental nerve was dissected and revealed. The facial artery and vein were exposed through a right submandibular skin incision and a subdermal tunnel was opened for the RFFF pedicle. In accordance with the preoperative plan, the dimensions of the defect were measured and noted, and two volumes of flap sketches were made on the left forearm, which was the nondominant side for this patient, with measurement in centimeters as per the preoperative plan. After Esmarch application, the flap was neurosensitively harvested with the medial antebrachial nerve for about 45 min, by working under 250 mmHg pressure tourniquet.

After harvesting, the flap was moved to the oral region. The first step was tunneling the pedicle before starting flap adaptation. Great care were taken to avoid rotation of pedicles. Adaptation sutures were started with 3-0 polyglycolic acid mucosal repairs of the lower lip. The mucosal part of the second flap was adapted to the upper lip mucosal area before reconstruction of the left commissure. In setting of the palmaris longus tendon was performed only for the skin island of the RFFF which would be used to reconstruct the lower lip with 3-0 polydioxanone sutures. Flap circulation was observed after the completion of microvascular anastomoses to the right facial artery and vein. After the completion of lateral antebrachial nerve to right mental nerve coaptation with 9-0 nylon microsutures, drains were placed and flap adaptation was terminated with skin closure.

The radial forearm donor site was reconstructed with a split-thickness skin graft taken from left femoral anterolateral region. Nasogastric catheter was inserted for early postoperative feeding. The patient was followed up closely in the intensive care unit (ICU) in the early postoperative period and extubated after 5 h. Thirteen hours later, the patient was transferred from ICU to the surgical ward.

Feeding with nasogastric catheter was ended on the 5th day postoperative and oral fluid feeding was started. On the 7th day, normal feeding was resumed. The patient was hospitalized for a total of 7 days. There were no complications in either the early or late postoperative periods. One year after surgery, two-point discrimination tests were measured as 6.5 and 5.5 mm on the upper lip and lower lip, respectively. The tests of heat sensitivity were sufficient to eat and drink hot or cold nutrients.

  Discussion Top

Lip reconstruction options are unfortunately limited when performed with local flaps. Abbe flap,[7] Estlander flaps,[8] Karapandzic flaps,[9] Gilles fan flap,[10] and Bernard Burow Webster flaps[11] are popular for use with limited defects of the upper or lower lip. Subtotal and total lower or upper lip defect reconstruction choices must generally be a free flap. Local flaps are superior to pedicled distant or free distant flaps in terms of color and texture compatibility. Unfortunately, this mismatch will occur for every distant free flaps. The leading free flap options are: radial forearm flap; anterolateral thigh flap (ALT); latissimus dorsi muscle flap; gracilis muscle flap; and rectus abdominis muscle flap.[12],[13],[14],[15],[16] Methods that can be selected for both lower and upper lip, full-thickness defects are more limited. As described in the present case, two different free flap options can be considered in both upper and lower lip defects. However, harvesting two different flaps from two separate donor sites, increases the morbidity, prolongs the surgical time, and requires the participation of two different surgical teams which is not always feasible.

The use of partial latissimus muscle flap, which may be innervated or spontaneously neurotized for functional gain, is a further option.[13] However, the absence of the orbicularis oris muscle decreases the value of the muscle flaps that will heal with neurotization. In addition, it is thought that fasciocutaneous flaps have a better cosmetic appearance and provide a more successful water-proof repair, when compared to muscle flaps, which may be used in the oral region with motor nerve coaptation.

Subscapular system-based muscle flaps, such as the serratus anterior and/or latissimus dorsi muscle flaps, can be used for both upper and lower lip reconstruction in a single session, but this requires a change of patient position during surgery, while cosmetic insufficiency and sensory inability make this choice disadvantageous. The addition of skin islands to these muscle flaps makes the flap bulkier and the increase in flap volume makes this choice untenable for lip reconstruction.

ALT flap may form a sensory fasciocutaneous flap, with lateral cutaneous femoral nerve, for lip reconstruction. A multiple skin island design on multiple skin perforators and chimeric flap choices can make an ALT a versatile flap.[15] However, the thickness of the skin and the inelastic tissue make it almost impossible to reconstruct both mucosa and skin for upper and lower lip. Different flap designs, such as using the fascia lata for reconstruction of a mucosal surface is possible but the fascia lata is not suitable as it is not water-impermeable. In addition, the flap choice for full-thickness lip reconstruction needs to be more pliable to be acceptable. Although, it is possible to harvest an ALT flap with a similar depth to an RFFF, the ALT is usually not suitable for folding at a 90° angle to its own surface.

The choice of RFFF has many advantages for reconstruction of full-thickness upper and lower lip defects. Since RFFF is thin, pliable, easy to harvest, neurosensitive, has a long pedicle length and facilitates surgical planning for two, free-moving, skin islands for both the skin and mucosa of the upper and lower lips.

The timing for operation was on the 10th day after burn injury. Although it was out of the ideal timing for microsurgical reconstruction, it was thought that immediate functional and cosmetic reconstruction would be better for early rehabilitation. It was thought that it was a better decision to carry out the operation, knowing the current risk, rather than waiting for an extra 30 days with a full-thickness necrosis on both upper and lower lips. Despite the risk about the timing on subacute period, there was no additional medication except 2 ml × 0.4 ml low-molecular-weight heparin.

  Conclusion Top

This is the first case report of a high-voltage electric burn to both upper and lower lips resulting in almost total necrosis which was reconstructed with an RFFF. The RFFF has many advantages including that it can be obtained relatively quickly through radial artery, concomitant veins and cephalic vein, thanks to radial artery perforators. When using an RFFF double skin islands can be planned, the flap may be neurosensitive with lateral or medial antebrachial cutaneous nerves, may be osseocutaneous with partial radial bone excision, has wide and long pedicles, and is very flexible and thin. In simultaneous defects of both upper and lower lip, including commissure, the use of a neurosensitive RFFF provides highly effective cosmetic and sensory results in single-session reconstruction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Hülsbergen-Krüger S, Pitzler D, Partecke BD. High voltage accidents, characteristics and treatment. Unfallchirurg 1995;98:218-23.  Back to cited text no. 1
Acosta AS, Azarcon-Lim J, Ramirez AT. Survey of electrical burns in Philippine General Hospital. Ann N Y Acad Sci 1999;888:12-8.  Back to cited text no. 2
Arnoldo BD, Purdue GF, Kowalske K, Helm PA, Burris A, Hunt JL. “Electrical injuries: A 20-year review. J Burn Care Rehabil 2004;25:479-84.  Back to cited text no. 3
Rai J, Jeschke MG, Barrow RE, Herndon DN. Electrical injuries: A 30-year review. J Trauma 1999;46:933-6.  Back to cited text no. 4
Thomas SS. Electrical burns of the mouth: Still searching for an answer. Burns 1996;22:137-40.  Back to cited text no. 5
Dallar Y, Bostanci I, Atli O. Indoor electric burns in children. Ulus Travma Acil Cerrahi Derg 2005;11:35-7.  Back to cited text no. 6
Nyame TT, Pathak A, Talbot SG. The abbe flap for upper lip reconstruction. Eplasty 2014;14:ic30.  Back to cited text no. 7
Quick B. The Estlander-Abbe operation. Aust N Z J Surg 1946;16:142-8.  Back to cited text no. 8
Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93-7.  Back to cited text no. 9
Bello SA. Gillies fan flap for the reconstruction of an upper lip defect caused by noma: Case presentation. Clin Cosmet Investig Dent 2012;4:17-20.  Back to cited text no. 10
Campos MA, Varela P, Marques C. Near-total lower lip reconstruction: Combined Karapandzic and Bernard-Burrow-Webster flap. Acta Dermatovenerol Alp Pannonica Adriat 2017;26:19-20.  Back to cited text no. 11
Dewey EH, Roche AM, Lazarus CL, Urken ML. Total lower lip and chin reconstruction with radial forearm free flap: A novel approach. Am J Otolaryngol 2017;38:618-25.  Back to cited text no. 12
Özkan Ö, Özkan Ö, Çinpolat A, Ubur MC, Bektaş G, Jumshudov A, et al. Functional lower lip reconstruction with the partial latissimus dorsi muscle free flap without nerve coaptation. Microsurgery 2019;39:131-7.  Back to cited text no. 13
Cakmak MA, Cinal H, Barin EZ, Sakat MS, Karaduman H, Tan O. Total lower lip reconstruction with functional gracilis free muscle flap. J Craniofac Surg 2018;29:735-7.  Back to cited text no. 14
Lai CL, Ou KW, Chiu WK, Chen SG, Chen TM, Li HP, et al. Reconstruction of the complete loss of upper and lower lips with a chimeric anterolateral thigh flap: A case report. Microsurgery 2012;32:60-3.  Back to cited text no. 15
Jallali N, Malata CM. Reconstruction of concomitant total loss of the upper and lower lips with a free vertical rectus abdominis flap. Microsurgery 2005;25:118-20.  Back to cited text no. 16


  [Figure 1], [Figure 2]


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