Microsurgical Replantation of the Lip: A Multi-Institutional Experience

Abstract

Traumatic amputation of the lip is a rare yet devastating event affecting both form and function. Considering the available methods for reconstruction, replantation may offer a reasonable solution. We sought to characterize the variables associated with lip replantation and to assess the outcome in a retrospective review of 13 lip replantations performed in 12 institutions utilizing a form database and clinical and photographic analysis. Lip replantation was successful in all 13 patients; partial flap loss occurred in one patient owing to iatrogenic injury. Follow-up averaged 3.1 years. Average patient age at the time of injury was 21.1 years. There were six male and seven female patients. Injuries in two patients were the result of a human bite, the remaining injuries resulted from dog bites. One patient had significant associated injuries. Average length of hospital stay was 11.9 days. Ten patients suffered amputations of the upper lip, and three suffered amputations of the lower lip. Average defect size was 10.6 cm2. Operative time averaged 5.7 hours (range 2.5 to 12 hours). Warm ischemia time averaged 2.9 hours, and cold ischemia time averaged 2.7 hours. Donor and recipient veins were often scarce; all patients had at least one arterial anastomosis, whereas no vein was available in 7 of 13 patients; vein grafts were required in one patient. Leech therapy was employed in 11 of 13 patients. Anticoagulant therapy was administered in the majority of patients. Systemic heparin was utilized in 10 of 13 patients, low molecular weight dextran was used in 7 of 13 patients, and aspirin was given to 7 of 13 patients. One bleeding complication was incurred. An average of 6.2 units of packed red blood cells was administered to 12 of 13 patients (adjusted to 250 cc/unit). Antispasmodic therapy was employed in six of eight patients intraoperatively and in two of eight patients postoperatively. Intraoperative complications included difficulty identifying veins in 7 of 13 patients, arterial spasm in 1 of 13 patients, and vessel diameter < 0.5 mm in 4 patients. Postoperatively, one patient suffered vein thrombosis requiring anastomotic revision. Broad spectrum antibiotics were administered to all patients, and there were no infections. Nearly one-third (4 of 13) patients suffered prolonged edema lasting > 4 months. Color match of the replanted lip segment was rated excellent in all cases. Hypertrophic scarring occurred in 6 of 13 patients. A total of 12 revision procedures was performed in six patients. Interestingly, leech therapy resulted in permanent visible scarring as a result of the leech bite in 6 of 11 patients treated. Ten patients demonstrated active orbicularis muscle contraction in the replanted lip segment. Stomal continence was present in all lips. Sensibility return in the replanted lip segment was quite good with 12 of 13 patients demonstrating at least protective moving two-point sensibility (> or = 10 mm). Partial replant necrosis in one patient resulted in significant scar and contraction that compromised th...

Leech Therapy for Patients With Surgically Unsalvageable Venous Obstruction After Revascularized Free Tissue Transfer

“…At the time of initial tissue transfer, the use of leeches when no venous anastomosis is possible has rarely been reported for free flaps, but it is well established for digit, 24 auricle, 25,26 nose, 27 and lip 28 replantation. Leech therapy used for salvaging head and neck free flaps that would otherwise require another major reconstruction is not as well described.…”

“…Of his own 18 cases, de Chalian found an average transfusion requirement of 4.4 U of packed red blood cells. As many as 14 U for free flaps 13 and 17 U for replants 28 have been reported. Thus, patients undergoing leech therapy need to be properly counseled about the likely need for blood transfusions and the associated risks.…”

Lip replantation and delayed inset after a dog bite: A case report and literature review

“…In the largest series, Walton et al 1 published a review of 13 replants from 12 institutions. Duroure et al 2 published a series of three cases in France and the remaining publications are single case studies.…”

Microsurgical lip replantation: Evaluation of functional and aesthetic results of three cases

“…The most common causes of traumatic lip amputation are dog bites and human attacks. 12 Preservation of amputated lip segments is the same as for other tissues. They should be kept in a closed plastic bag put in an ice container.…”

“…In a review of the literature, more than 50% of lip replantations were made without any venous anastomosis. 12 Even when an anastomosis is possible, there is a postoperative phase of venous congestion, which will require a substitution procedure. Venous drainage could be obtained by leech therapy, local application of heparin, local injection of anticoagulant in the replanted segment, and systemic anticoagulant therapy.…”