JC ZISSER FLAP.pptx oral and maxillofacial surgery

Zisse flap

1. JOURNAL CLUB PRESENTATION GUIDED BY- DR.VIKAS KUNWAR SINGH SIR HOD AND PROFESSOR DEPT. OF ORAL AND MAXILLOFACIAL SURGERY MGDCH , JAIPUR. DR.RUCHIKA TIWARI MA’AM PROFESSOR AND GUIDE DEPT. OF ORAL AND MAXILLOFACIAL SURGERY MGDCH , JAIPUR. PRESENTED BY- DR.DIVESH JAIN PG 1 ST YEAR DEPT. OF ORAL AND MAXILLOFACIAL SURGERY MGDCH , JAIPUR.

2. INTRODUCTION Lip is a 3-layered anatomic unit, consisting of skin, muscle, and mucosa. From an esthetic aspect, the lip is undoubtedly one of the most unique, prominent elements of the facial appearance, conveying expressions, as well as recognizable beauty and appeal. Considering , the complex anatomy and the multiple functions of this facial region, it is easy to understand that reconstruction of a labial defect represents a daunting challenge to the surgeon. Important parameters for choosing 1 of the over 100 reconstruction techniques are the size, location, and depth of the perioral defect, as well as the preference and personal experience of the surgeon. Surgical reconstruction of perioral tumor–related defects requires observing specific principles of oncology and resecting the malignant disease while preserving healthy margins.

3. Secondary consideration must be given to the best possible functional outcome and realizing patients’ esthetic expectations and wishes. Undoubtedly, the oral commissure is the most difficult region to reconstruct from a functional and esthetic point of view.

4. AIMS The aims of the study is to investigate the functional and esthetic benefit of reconstruction of the oral commissure by means of a combined cheek-skin advancement and an intraoral mucosal flap ( Zisser flap ) in a series of 13 patients over a period of 14 years

5. Materials and Methods The records of all patients treated by oral commissuroplasty with the Zisser flap in the period between 2003 and 2017 were evaluated. All patients were evaluated preoperatively by clinical examination and by ultrasonography and/or computed tomography of the head and neck, as well as by photographic documentation. The functional result of the reconstruction of the oral commissure was assessed regarding postoperative subjective speech integrity, preservation of competence of the oral sphincter, and lip sensation. The esthetic outcome was evaluated regarding limitations in facial expression and scar formation by means of a clinical evaluation method.

6. SURGICAL TECHNIQUE In the case of commissural tumors , the tumor area as well as the planned resection is marked. The flap is designed to include the nasolabial and melolabial folds on both sides .

7. The tumor is resected, and tumor-free resection margins are verified by means of frozen section . Subsequently, the position of the neo-commissure is planned by measuring the distance from a point between the philtral columns and the uninvolved commissure. It is important to keep in mind that the intercommissural distance is between 4 and 5 cm when the lips are closed and relaxed A triangular excision through the skin and subcutaneous fat tissue is then carried out superiorly and inferiorly to the defect in the oral commissure . The resulting crescentic defect of the soft tissue allows medial advancement of the lateral soft tissue components of the cheek

8. A full-thickness horizontal incision is placed at the same level as the original commissure. Above and below this horizontal full-thickness incision, 2 triangular areas are de-epithelialized. Subsequently, the soft tissues of the cheek are mobilized to cover the commissural defect, and the buccal (or lingual) mucosa above and below the horizontal incision is used to reconstruct the oral commissure.

9. All wounds are closed in a tension-free manner. A nasogastric feeding tube is placed for 3 to 5 days.

10. Postoperative outcome with symmetrical restoration of bulk and alignment of right oral commissure.

11. DISCUSSION Undoubtedly, the oral commissure is the most difficult region to reconstruct from a functional and esthetic point of view. The complexity of this region brought Bakamjian to define surgical restoration of its functional integrity as an ‘‘almost unreachable objective’’ in 1964. More than 200 reconstruction techniques with different donor sites have been suggested. Reconstruction of a vertically oriented commissural defect by means of combined cheek-skin advancement and an intraoral mucosal flap was first described in 1975 by Zisser . The proximity to the natural perioral creases (nasolabial and melomental folds) and the age-related flaccidity of the soft tissues of the cheek, as well as the elasticity and pliable lining of the oral mucosa, in combination with the simplicity of the reconstruction steps, offer ideal circumstances for a satisfactory surgical outcome

12. The same result can be achieved with other reconstruction techniques ( eg , the Estlander flap using the lesser affected lip), the comparative disadvantage being the risk of microstomia and the potential necessity for a secondary procedure (transection of the flap pedicle or secondary commissuroplasty with expansion of the oral cleft) The Fries and Brusati techniques have the disadvantage of placing the skin incisions of the U-shaped flap vertical to the relaxed skin tension lines with the potential risk of a poorer cosmetic result In contrast, the Zisser technique stipulates that skin incisions be placed in the natural nasolabial and melolabial folds parallel to the relaxed skin tension lines In accordance with the relevant literature, medialization of the commissure with subsequent microstomia was not an issue in our series, as there was a net gain in the lip through the advancement of the soft tissues of the cheek up to the desired position of the neocommissure .

13. Similarly, blunting of the oral commissure (rounded appearance with poor angle definition of the commissure, particularly noticeable when the lips are open was not observed in this technique as a new labial angle was constructed without any tissue rotation being required. This constitutes a major advantage over the Estlander flap, in which the switch of the lateral lip to the commissural defect is associated with a high risk of commissural blunting and microstomia

14. RESULTS The commissural defect was caused by tumor removal in 10 cases, by trauma in 2, and by a burn in 1. Vermillion reconstruction was achieved by means of a buccal mucosal flap in 11 cases and a lingual mucosal flap in 2. The mean esthetic outcome was 6.84 and the mean functional outcome was 3.6. In 1 case, reduced patient compliance with deliberate removal of the nasogastric tube and premature oral intake led to dehiscence of the buccal flap and insufficiency of the reconstructed oral commissure with loss of oral sphincter competence. In this case, secondary commissuroplasty with restoration of sphincter function was achieved with a routine closure of all tissue layers of the commissure up to the desired position of the neo-commissure. No cases of blunting or microstomia were detected. Speech integrity was quite acceptable in all of our study cases

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