(A590) Oral Commissure Reconstruction with Zisser Flap, Vermilion Mucosal Advancement, and Pedicled Buccal Fat Pad Flap

Introduction: Reconstruction of the oral commissure presents challenges given its functional and cosmetic importance. We describe a case utilizing a modified Zisser advancement flap for a patient with recurrent buccal squamous cell carcinoma. Preoperatively, the patient had poor oral competence with drooling due to damage to the facial nerve buccal branches from a prior resection. Using the technique described here, the patient was able to regain mouth opening and oral competence with an excellent cosmetic outcome.

Methods: The malignant lesion was excised, resulting in a large buccal defect measuring 4x4 cm and a smaller cutaneous defect measuring 2x2 cm. The defect extended over the mandibular alveolus and involved the right upper and lower lip. The lingual gingiva and floor of mouth mucosa were advanced to cover the exposed bony area. A buccal fat pad pedicled flap was advanced to cover the intraoral defect. Superiorly and inferiorly based triangles were excised along the nasolabial and melolabial folds. A laterally oriented triangle and horizontal incision was made at the level of the new right oral commissure to create a new oral commissure. Due to lack of intraoral mucosa to reconstruct the new mucosal lip along the commissure, a vermilion mucosal advancement flap was performed on both the upper and lower lip.

Results: One month postoperatively, the wound was healing without dehiscence, and the patient was tolerating a regular diet without drooling from the mouth.

Conclusions: We present a patient with a full-thickness oral commissure defect extending posteriorly along the buccal mucosa and mandibular alveolus with oral incompetence. Given the wide buccal defect, reconstruction with a traditional Zisser flap to recreate the oral commissure was inadequate. We demonstrate a Zisser flap in conjunction with vermilion mucosal advancement and a pedicled buccal fat pad flap is an efficacious method to functionally and aesthetically repair oral cavity defects involving the oral commissure. Our technique successfully elevated the oral commissure to correct his preoperative drooling.