Upper Lip Replantation with Arterialized Venous Flap, Without Microsurgical Venous Outflow
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A 52-year-old female presented at the emergency department of our hospital after a dog bite with a partial avulsion of the upper lip. The amputated part originated between the philtrum and the left nasolabial fold. On exploration of the fragment, a lateral vein of 1 mm diameter was preoperatively identified, but no artery was found in the amputate. An arteriovenous anastomosis with the left superior labial artery was performed. Venous outflow was achieved by using leeches and heparin compresses. No necrosis or other complications were seen at the replanted upper lip and achieved an aesthetically satisfactory result. Follow-up after 8.5 months showed good healing of the upper lip. The satisfactory result in this case and literature research show that microsurgical replantation should always be considered, which results in a better aesthetic and functional outcome.
KeywordsMicrovascular Anastomosis Microsurgical Replantation Reimplantation Lip
The Clinical Scenario
Upper lip avulsions are common in facial dog bites. In Belgium, around 100.000 people get bitten by a dog every year with a high prevalence in children of 22 out of 1000 per year. Children are bitten in the face more often because of their smaller stature and relatively larger head. 20% of all cases visit the emergency department, 40% the general practitioner, and 40% provides the wound care at home (De Keuster et al. 2006; Kahn et al. 2003; Morgan and Palmer 2007).
Preoperative Problem List
Preoperatively, only a small lateral vein of 1 mm diameter was identified. No artery was found in the amputate. This resulted in a challenging replantation case.
Treatment Plan and Alternative Reconstructive Options
Since infection is the most common complication of a dog bite, prophylactic antibiotics should be administrated. β-lactam antibiotics with a β-lactamase inhibitor are preferred, such as amoxicillin + clavulanic acid (three times 500/125 mg per day), given the wide range of microorganisms that may be responsible for infection. In the case of allergy to β-lactam antibiotics, doxycycline (200 mg per day) can be given, or in children under 12 years of age and pregnant women, erythromycin (BCFI 2003).
Bite wounds are normally not sutured primarily due to the risk of infection. However, when aesthetic outcome prevails, this can still be considered after thorough rinsing and disinfection of the wound. In addition, as few subcutaneous stitches as possible should be used, as any foreign material in a contaminated wound increases the risk of infection. In this clinical case, since the lacerations are located on the face, it was decided to suture them.
There is a high risk of tetanus with bite injuries. Correct immunization against tetanus is therefore of great importance.
The primary vaccination of infants against tetanus occurs with a combined hexavalent vaccine and starts at the age of 8 weeks (recommended and at the earliest 6 weeks). It consists of three doses with intervals of 4 weeks each (8, 12, and 16 weeks) and a repeat vaccination at the age of 15 months. A minimum period of 6 months should be respected between the third dose of the primo vaccination and the repeated vaccination. A complete basic vaccination against tetanus for an adult includes three injections: the second injection is given 4 to 6 weeks after the first and the third about 6 months to 1 year after the second (BCFI 2003).
Vaccination status of the injured
Severity of the injury
Superficial and clean
Wound with risk of tetanus
1. No or uncertain vaccination
Complete primo vaccination
Complete primo vaccination and specific immunoglobulins
2. Incomplete primary vaccination
Finish vaccination schedule
Finish vaccination schedule and specific immunoglobulins
3. Complete primo vaccination
a) Last vaccination <5 years ago
b) Last vaccination>5 years and < 10 years ago
Toxoid (1 dose)
c) Last injection>10 years and < 20 years ago
Toxoid (1 dose)
Toxoid (1 dose) and specific immunoglobulins
d) Last injection>20 years ago
Toxoid (2 doses with 6-month interval)
Toxoid (2 doses with 6-month interval) and specific immunoglobulins
Dogs are important hosts and vector of the Rabies virus; therefore, dog bites have a high risk for Rabies infection. Cats can transmit the disease, but do not seem to host the virus.
In case of known Rabies or when Rabies is not proven but (highly) suspected, the bitten patient needs to be vaccinated, and specific immunoglobulins against rabies are administered simultaneously. If the animal can be observed for 10 days after a bite and there is no evidence of Rabies during that period, the immunization schedule may be interrupted or immunization should no longer be initiated. If the animal develops or dies any signs of rabies within 10 days of the bite, it must be tested; if Rabies infection is diagnosed, the immunization must be continued or started (BCFI 2003).
Replantation of the Amputate
For the amputate, a microsurgical replantation should always be considered which results in a far more satisfactory aesthetic and functional outcome. However, if replantation is not possible, other options such as primary closure, using the amputate as composite graft or reconstruction with a (local) flap, can be considered as an alternative solution. These alternative options will be discussed below. However, when opting for replantation of the lip, this can be performed with one or two arterial anastomoses. Although a venous anastomosis can be achieved in most cases, a sufficient venous outflow is the greatest obstacle to the success of the replantation. Since functional veins are created 4 to 6 days post-replantation via neoangiogenesis, this critical period must be bridged by techniques to facilitate venous drainage such as leech therapy (Hirudo medicinalis, with or without topical heparin), mechanical pricking and the use of topical heparin or intra-replant heparin or administering (additional) mono- or multi-anticoagulant/antiaggregant therapy such as heparin, aspirin, dextran, and/or warfarin. Since these techniques maintain an active bleeding, hemoglobin (Hb) should be closely monitored so that blood transfusions can be made in time (Mumcuoglu 2014; James 1976).
The medicinal leech or Hirudo medicinalis has been used for over 50 years to remedy venous congestion. And certainly today too, grateful use is made of leech therapy as a lifebuoy in reconstructive microsurgery. The FDA approved leech therapy as a medical device in the field of plastic and reconstructive surgery in July 2004.
Leech therapy is a relatively safe and well tolerated. However, it is important to take the risk of infection into account caused by the Aeromonas bacteria, which are symbionts of leeches. These bacteria are sensitive to second- and third-generation cephalosporins, fluoroquinolones, sulfamethoxazole-trimethoprim, tetracycline, and aminoglycosides but are resistant to penicillin, ampicillin, first-generation cephalosporins, and erythromycin. Therefore, patients should be treated each day of leech therapy with anti-Aeromonas antibiotics such as 500 mg of ciprofloxacin.
One to ten leeches are used for each treatment. Different protocols have been described, ranging from three leeches per hour to leeches applied every few hours. Most protocols are established empirically and adjusted based on the degree of congestion of the flap during the therapy.
Before application, leeches are thoroughly rinsed with deionized water. When the leech is attached, a plastic adhesive membrane or a thick layer of gauze can be applied to keep the leech on the treatment area. The leeches normally start feeding immediately. If not, the skin can be punctured with a sterile needle to stimulate the leeches with the released blood.
The treatment lasts for 30 to 90 min after which the leech releases itself. During feeding, the leeches can release a clear liquid: this is superfluous water that they remove to concentrate the red blood cells in their digestive tract.
After detachment of the leech, compresses soaked in isotonic sodium chloride solution or heparin solution (5.000 U/mL) can be applied to the treatment area to maintain the active bleeding. The total treatment with leeches lasts for 2–6 days considering the fact that functional veins are created 4 to 6 days post-replantation via neoangiogenesis.
Additional mono- or multi-anticoagulant/antiaggregant therapy can be administered such as heparin, aspirin, dextran, and/or warfarin, although the leech saliva also has some antithrombotic activity. Patients may lose 5 to 15 mL of blood per leech treatment. But due to the anticoagulant/antiaggregant therapy, a greater blood loss must be assumed. Therefore, hematologic evaluations should be performed regularly (every 4 h), and hemoglobin (Hb) should be closely monitored so that necessary blood transfusions can be made in time (Mumcuoglu 2014; James 1976).
Alternative Reconstruction Techniques
If replantation is not possible, following the reconstructive ladder, the first step in lip reconstruction is primary closure with or without wedge excision. It is of utmost importance to correctly identify the vermillion border and to respect this anatomical border during reconstruction. With lower lip defects, especially in patients with high laxity of the tissues (e.g., elderly), up to 60% can be closed primary. If microstomia should occur, this can be remedied with physiotherapy (stretching exercises) so that normal function can be regained. In contrast to the lower lip, reconstruction of the upper lip is somewhat more limited; only a defect of maximum 40% can be primarily closed. This is mainly because a possible lateral shift of the philtral columns immediately reveals an earlier reconstruction and thus an aesthetic inferior result.
The Abbe flap, also known as the “lip switch flap,” was published by the American surgeon Robert Abbe in 1898. Although the flap has already been described by Pietro Sabattini 60 years earlier, in a book with a limited circulation which explains the unfamiliarity of this fact, it remains known under the name Abbe flap.
The flap is a two-staged pedicled flap based on the arteria labialis inferior or superior and can be used, respectively, for both upper and lower lip reconstructions, although it is most commonly used for upper lip reconstruction with central or lateral lower lip as donor site. The flap is designed half as wide as the defect to obtain equal upper and lower lip lengths and with the same height as that of the defect. The flap consists of the skin, muscle, and mucosa. After harvesting, the flap is rotated and inset with respect to the anatomical landmarks, in particular the aligning of the vermilion border and the orbicularis oris muscle. The pedicle, a small amount of mucosa and also the labial artery are divided after two to three weeks (Baumann and Robb 2008).
Jakob August Estlander was a Finnish surgeon who described the flap in 1872, which is used for defects of the lower or upper lip involving the oral commissure. The technique is similar to the Abbe flap, but a correcting second-stage commissuroplasty is often needed around 12 weeks after the first procedure (Quick 1946).
The Karapandzic was reported in 1974 by Miodrag Karapandzic, a Yugoslavian plastic surgeon, as a “rotation advancement lip flap” which is used as a one-stage flap for defects involving half of the upper lip or larger. A defect is restored by separating the orbicularis oris muscle while maintaining the nerve and blood supply intact and then rotating and advancing until closure of the oral sphincter. Because the net circumference becomes smaller, microstomia can occur. This can be remedied in most cases through physiotherapy that results in a good recovery of the initial function since the orbicularis muscle remains innervated (Karapandzic 1974).
Surgical Technique, Patient Management, and Outcome
In this clinical case, only a small lateral vein of 1 mm diameter was identified. No artery was found in the amputate. This resulted in a challenging replantation case since not only the venous outflow but also the arterial inflow was compromised. The total ischemia time was approximately 5 h, and the surgery time was 2 h and 40 min.
Since no microsurgical venous anastomosis could be provided, techniques to facilitate venous drainage were needed. In this clinical case, venous outflow was achieved by using leeches, which were changed every 3 h. Heparin compresses, soaked in a solution of 5000 UPS units/mL heparin with 30 mL NaCl, were applied locally on the flap. The leech therapy was extended to every 4 hours at day 6 and stopped at day 9 postoperatively. Due to the active venous bleeding, a total of two units packed red blood cells were administered at day 7 postoperatively.
Prophylactic antibiotics to prevent infections related to dog bites (amoxicillin/clavulanic acid) and infections associated with leech therapy (ciprofloxacin) were started (BCFI 2003). Prophylactic low-molecular-weight heparin (0.4 cc 1dd) for deep vein thrombosis prevention was also started. The patient was installed with the upper body in a 30 ° upright position. Warmth was applied over the face by using a hot air blanket set at 43 °C. The systolic blood pressure was kept around 120 millimeters of mercury.
The patient was intubated for 9 days to accommodate leech treatment. Due to respiratory complications, intubation was prolonged for 4 days.
No necrosis or other complications were seen at the replanted upper lip and achieved an aesthetically satisfactory result. Follow-up after 8.5 months continued to show a good healing of the defect. Also a full recovery of sensory and motor function was seen.
In this case, noninvasive heat was applied to the face using a hot air blanket at 43 ° C, which gave a significant clearance of the cyanotic appearance of the replanted part.
As demonstrated by this case, the inability to perform a venous anastomosis is not a contraindication for replantation. Also, performing an artery-to-vein anastomosis appears to be a reliable alternative when no artery can be found in the amputate. Therefore, a microsurgical replantation should always be considered which results in a far more satisfactory aesthetic and functional outcome.
The continuous use of leeches near the mouth as well as noninvasive heating of the face, which are both strongly recommended to avoid venous congestion even with patent venous anastomosis, require postoperative intubation of the patient for the duration of the therapy. To avoid any complications due to a longer period of intubation, this period should be kept as short as possible. Since neoangiogenesis occurs in a period of 4 to 6 days, a maximum duration of 7 days leech therapy followed by extubation should be considered (Mumcuoglu 2014; James 1976).
- BCFI. Aanpak van bijtwonden door katten en honden [Internet]. BCFI. 2003 [cited 2018Apr21]. Available from: http://www.bcfi.be/nl/articles/1225?folia=1217.