Oral mucosal lesions such as hyperkeratosis can enlarge and involve adjacent anatomic structures. Surgical treatment may cause significant morbidity in terms of loss of function due to scarring and compromised aesthetics due to failure to restore the original muscle anatomy and overlying soft tissue. The authors present a case of hyperkeratosis of the oral commissure and buccal mucosa, which was successfully reconstructed by using vermilion myomucosal flap and A-T advancement.
Buccal mucosa lesions may involve the oral commissure or its adjoining vermilion layer. From a surgeon’s perspective this anterior extension has significant implications as it may lead to postoperative functional and aesthetic deficits. The authors present a novel adaptation of two different wound closure techniques for reconstructing a defect arising after surgical excision of a benign hyperkeratotic lesion involving oral commissure, adjacent vermilion and anterior buccal mucosa. The patient required surgical excision for aesthetic and psychological reasons. Any surgery involving the oral commissure can damage the functional balance of facial muscles. Restoring the sphincteric integrity of the orbicularis oris is important. The authors opted for the vermilion myomucosal flap technique for reconstruction of the oral commissure. The defect arising in the buccal mucosa was triangulated to form an ‘A’ shape. The labial mucosal incisions of the two vermilion flaps were designated as horizontal limbs of inverted T closure as in the A-T plasty technique.
The lesion extended for 1 cm along the vermilion layer of the upper and lower lips from the commissure. Posteriorly it involved 1.5 cm of the buccal mucosa ( Fig. 1 ).
Under local anaesthesia, the lesion was excised, including the underlying muscle bed and 4 flaps were marked. A vermilion myomucosal flap was raised on the upper lip as far as the median tubercle and another, to the same extent, on the lower lip. Care was taken to include the labial vessels in both flaps. Undermining, below the peripheral orbicularis oris and buccinator muscles, was carried out for about 2 cm on both sides of the triangulated buccal mucosal ‘A’ defect, to allow tension free closure in its middle ( Figs. 2 and 3 ). The leading muscle edge of the two vermilion flaps was sutured subcutaneously at the location of the original commissure. The slack in the skin margin of vermilion flaps was accommodated by differential suturing. Intraorally the tips of the two triangular flaps were stretched towards the middle and were sutured at the muscular level to each other and to the two vermilion flaps. This manoeuvre ensured the continuity of the buccinator muscle with the orbicularis oris thereby restoring the original functional anatomy. The postoperative period was uneventful with all the incisions healing primarily. Excellent cosmesis, oral competence and unrestricted mouth opening was achieved ( Fig. 4 ).