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Functional and aesthetic evaluation of adjacent tissue flap repairing defects of oral commissure area

BMC Oral Health volume 25, Article number: 536 (2025) Cite this article

Abstract

Background

From a functional and aesthetic point of view, the oral commissure is the most difficult area to reconstruct in lip defects. It is a very complex and challenging task to rebuild the function and appearance of the oral commissure area with high quality.The aim of this paper is to discuss and compare the results of different methods for the reconstruction of defects in oral commissure area.

Methods

This study used five commonly used adjacent tissue flaps to reconstruct and evaluate postoperative oral function and appearance in patients who underwent repair of defects in the oral commissure region between September 2015 and June 2024. The primary outcomes were salivation, oral function, speech intelligibility, reconstructed lip tactility, Patient and Observer Scar Assessment Scale (POSAS) and patient postoperative quality of life evaluation.

Results

A total of 55 patients underwent surgical reconstruction of defects in oral commissure. At 6 months postoperatively, the McGregor and Colmenero groups demonstrated more statistically excellent oral motility compared to the other groups (p = 0.028).There was no significant difference in the effect of the different reconstruction on the patients’ speech expression and flap tactile sensitivity. The aesthetic outcomes were favorable in both groups. Quality of life was at a higher level in patients who underwent reconstruction with the Estlander, McGregor and Colmenero flaps (p = 0.036).

Conclusion

Taking into account the differences between each reconstruction method, the Estlander flap is the preferred method for small and medium-sized defects, the McGregor and Colmenero flap can better restore motor function.The methods of repairing defects of the oral commissure area described in our study do not differ significantly in speech expression, flap tactile sensitivity, or aesthetic outcomes. Postoperative quality of life is higher in patients reconstructed with Estlander, McGregor and Colmenero flap repairing.

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Introduction

Worldwide, the incidence rates for lip cancer has been increasing from 1990 to 2017 [1]. Primary malignant lip tumors account for 2.06% of all malignancies and approximately 30% of oral malignant tumors [2]. Of these, 1-15% involve oral commissure (the angle of the mouth, mouth angle) [3].Most of the lip defects in the clinic are caused by postoperative tumors, trauma, infection and other acquired factors [4]. The most common cause of defects in the oral commissure area is due to tumor resection [5, 6].The angle of the mouth is located at the intersection of the upper and lower lips on both sides, which is an important subunit of body surface aesthetics, including the orofacial axis as the common stopping point of the facial expression muscles, and it also plays a vitally important role in facial expression innervation, lip movement, and other functions [7]. Undoubtedly, the oral commissure is the most difficult region to reconstruct from a functional and aesthetic point of view [8]. The complexity of this region has led Bakamjian (widely regarded as the “father of modern head and neck reconstruction”) to define the restoration of its function using surgical techniques as an “almost unreachable objective” [8,9,10,11]. To this day, shaping the oral commissure with functional and artistic prognosis remains a challenging task [12].

This paper retrospectively analyzes 55 patients who underwent tumor resection and defect reconstruction of the oral commissure region between September 2015 and June 2024 and discusses the functional and aesthetic advantages and disadvantages of reconstructing the oral commissure region through different methods.

Patients and methods

Patients

The study was designed as a single-center, retrospective clinical trial. The study project was approved in advance by the Institutional Review Board of China Medical University (Shenyang, Liaoning, China, number: K2024040). All patients participating in the study were informed of the aim and process of the study prior to enrollment and signed an informed consent form. Patients should be excluded if they had undergone previous surgery, radiotherapy, chemotherapy or trauma in the region. In addition, patients who underwent reconstruction but lacked adequate documentation or lost to follow-up should not be included.

Because there is no uniform classification of defects in the angle of the mouth, and sometimes there are combined defects of the cheek, zygomatic, chin, and even defects involving the maxilla and mandible, we classified the defects of oral commissure according to the range of defects involving only the lower lip, involving only the upper lip, and involving both the upper and lower lips. Depending on the size of defects, we decide which flap to use for each patient. Specifically, if the defect is larger than 1/3 of the whole lip but less than 1/2 of the whole lip, the Estlander flap [13] is used for repair and reconstruction; if the defect is up to 1/2 of the whole lip, the modified McGregor flap [14] and the Fries flap [15] are used; if the defect is larger than 1/3 of the whole lip and less than 2/3 of the whole lip, the Fujimori flap [16,17,18,19] and the Colmenero flap [20] can be used. Patient demographics and preoperative clinical data were collected and evaluated for postoperative complications including, but not limited to, infection, wound dehiscence, flap necrosis, and cancer recurrence.

Typical case

Case presentation 1 -Estlander flap

Patient, male, 71 years old, left lower lip near the corner of the mouth was broken for 8 months, and tissue biopsy confirmed SCC with stage T1N0M0. We used the Estlander flap for reconstruction of the defect after tumor resection and the patient had no postoperative complications. At 6 months follow-up the patient had a well healed and good oral mobility to pucker the lips (Fig. 1).

Fig. 1
figure 1

Case photos of Estlander flap. (A) Squamous cell carcinoma of the left lower lip near the corner of the mouth; (B) Design of the incision line for tumor resection and the Estlander flap; (C) Reconstruction completed; (D) Closed mouth photo of the patient 2 weeks after surgery; (E) Closed mouth photo of the patient 6 months after surgery; (F) Blow photo of the patient 6 months after surgery

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Case presentation 2-modified McGregor flap

Patient, male, 57 years old, with T2N0M0 SCC of the lower lip, underwent extended resection of the lesion, and reconstructive repair was performed using a modified McGregor flap. 6 months after the operation, the degree of opening and opening pattern reached the normal standard, the tactile sensation in the reconstructed area returned to the normal level, and the device could be inflated(Fig. 2).

Fig. 2
figure 2

Case photos of McGregor flap. A. Resection and flap preparation completed; B.Reconstruction completed; C. The Semmes-Weinstein monofilament test of the patient 6 months after surgery. D. Blow photo of the patient 6 months after surgery

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Case presentation 3-Fries flap

A 72-year-old woman was found to have ulceration of the left corner of the mouth for six months and was diagnosed with SCC on tissue biopsy, with the lesion involving the left corner of the mouth. We planned to use the surgical plan of extended resection of the lesion + Fries flap reconstruction, and the intraoperative process was smooth with good reconstruction results. 6 months after the operation, the patient did not see any obvious complications, and the speech recovery was close to the preoperative level. She was able to pucker her lips but could not close the upper and lower lips tightly, and the patient reported that there were occasional spills when she ate (Fig. 3).

Fig. 3
figure 3

Case photos of Fries flap. A. Squamous cell carcinoma of the left corner of the mouth; B. Design of the incision line for tumor resection and the Fries flap; C. Resection and flap preparation completed; D.Reconstruction completed; E.Closed mouth photo of the patient 6 months after surgery; F. The Semmes-Weinstein monofilament test of the patient 6 months after surgery

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Case presentation 4-Fujimori flap

The patient was a 58-year-old male with SCC of the right upper lip near the right corner of the mouth.Surgical enlargement of the excised lesion was reconstructed using a Fujimori flap.At 6 months postoperatively, the patient was satisfied with the shape of the reconstructed area, with the opening recovered, he could pucker his lips, inflate the device, and the tactile sensation of the reconstructed area was at a normal level (Fig. 4).

Fig. 4
figure 4

Case photos of Fujimori flap. A. Squamous cell carcinoma of the right upper lip near the right corner of the mouth; B. Resection and flap preparation completed; C. Reconstruction completed; D. Appearance of the patient 6 months after surgery; E. Open mouth photo of the patient 6 months after surgery; FG. Blow photo of the patient 6 months after surgery; H. The Semmes-Weinstein monofilament test of the patient 6 months after surgery

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Case presentation 5-Colmenero flap

The patient was a 64-year-old male who underwent defect reconstruction with a Colmenero flap after enlarged excision for SCC of the left lower lip. Six months after surgery, the patient’s scar healed well, at rest the patient left a small gap at the corner of the mouth, and self-reported occasional salivation, but oral movements could be restored to the level of blowing (Fig. 5).

Fig. 5
figure 5

Case photos of Colmenero flap. (A) Squamous cell carcinoma of the left lower lip near the corner of the mouth; (B) Design of the incision line for tumor resection and the Colmenero flap; (C) Resection and flap preparation completed; (D) Reconstruction completed; (E) Open mouth photo of the patient 6 months after surgery; (F) Closed mouth photo of the patient 6 months after surgery; (G) Blow photo of the patient 6 months after surgery

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Postoperative outcomes

The Drooling Rating Scale (DRS) was used to assess the severity of drooling in daily activities in 55 patients at 6 months after surgery. The score was 0–3, and the higher the score, the more severe the degree of salivation. Oral competence was blindly assessed by asking the patient whether they could blow (excellent; blows, good; holds food, fair; rarely spills, poor; drooling at rest). Speech was assessed for intelligibility from the patients’ spontaneous speech by a simple grading system (grade I; normal, grade II; intelligible to others, grade III; intelligible to the family only, grade IV; unintelligible speech) [21]. Mouth opening movements were assessed by measuring the patients’ postoperative mouth opening. Tactile sensitivity of the flap was assessed by pressing different areas of the flap using Semmes-Weinstein monofilaments [22, 23].

For aesthetic assessment, 55 patients and 2 observers (Xuewei Jia, Changfu Sun) performed POSAS. A low score implies a better quality scar, and the cumulative score describes the overall quality of the scar [24].

All patients were scored for quality of life using the Washington Quality of Life Scale (4th edition). It includes 12 aspects that affect daily life after being subjected to treatment. The higher total score, the better quality of life.

Statistical analysis

The data were analyzed using IBM SPSS statistical software (windows version 26 (IBM Corp)). One-way ANOVA was used for the comparison of measurement data, chi-square test was used for the comparison of count data, and Kruskal-Wallis rank-sum test was used for the comparison of hierarchical data. All tests were two-tailed and considered statistically significant when p < 0.05.

Results

We retrospectively analyzed 55 patients, aged 55 ~ 82 years (mean 68.9 years), who were treated for tumors in the oral commissure region at the Department of Oral Maxillofacial-Head and Neck Surgery of the Stomatology Hospital of China Medical University from September 2015 to June 2024. There were 31 males (56.4%) and 24 females (43.6%).The pathological type of the 55 patients included squamous cell carcinoma (SCC) (33 patients, 60.0%), basal cell carcinoma (BCC) (10 patients, 18.2%), and verrucous carcinoma (12 patients, 21.8%). 12 patients (21.8%) had defects involving the upper lip, 32 patients (58.2%) were involved the lower lip, and 11 patients’ (20.0%) upper and lower lips were involved.13 patients were reconstructed with the Estlander flap, 12 patients with the modified McGregor flap, 9 patients with the Fries flap, 11 patients with the Fujimori flap and Colmenero flap in 10 patients. Once cervical lymph node infiltration was confirmed, we performed neck dissection. Postoperative nasogastric tube feeding was performed for 2 weeks. The distribution of patients’ age, sex, pathologic type, defect size, T-stage, repair method, and involvement are shown in Table 1.

Table 1 Demographic data of patients, pathologic type, defect size, T-stage, repair method, and involvement
Full size table

Follow-up was 6 months ~ 4 years. The size of the defects in the area ranged from 0.5 × 0.5 cm to 3.7 × 2.8 cm. The flap survival rate was 100% and all healed well. One patient (57 years old) developed ipsilateral cervical lymphatic metastasis 2 months after receiving the Estlander flap and underwent radical neck dissection. Another patient (72 years old) developed local recurrence 1 year after receiving the Estlander flap, and was treated with localized extended excision. The remaining patients had no complications such as infection, flap necrosis, wound dehiscence, recurrence and metastasis.

At 6 months postoperatively, control of salivation was more favorable in patients in the Fujimori and Colmenero groups, with more severe salivation occurring in the Estlander and Fries groups (p = 0.872).McGregor and Colmenero groups showed more superior oral motility (p = 0.028). Analyzing speech, 55 patients had normal speech. One patient in each of the Estlander and Fries groups had moderately limited mouth opening, while the rest had slightly limited or even normal mouth opening (p = 0.652) (Table 2).

All patients had no discomfort when consuming hot and cold food, and a total of 10 patients had numbness, but the difference between groups was not statistically significant difference (p = 0.906). The tactile sensitivity of the flap could regain in all patients; At the same time, the quality of life was at a higher level in patients who underwent reconstruction with the Estlander, McGregor and Colmenero flaps (p = 0.036)(Table 2).

Table 2 Postoperative functional outcomes
Full size table

No statistically significant differences were found in the comparison of POSAS between the groups (p > 0.05), and the overall quality of scar recovery was higher in the Estlander and McGregor groups of patients than in the other groups.(Table 3).

Table 3 Surgeon and patient Scar assessment 6 months after surgery
Full size table

Discussion

From the recognition of lip defect repair by Sushruta [25] in 1000 B.C. to present, there have been more than 200–300 methods of repairing lip defects. Although a number of methods have been recognized as more ideal for lip defects [8,9,10], none of them has reached perfection and none of them is suitable for the repair and reconstruction of all defects. The method of reconstruction for defects in the angle of the mouth is influenced by the type and extent of the defect, patient’s age, complications, and surgeon’s experience [26]. Regardless, the advantages of combining the anatomical features, color, thickness, and texture of the adjacent tissues of the oral commissure defects make adjacent flaps still predominant in the repair and reconstruction of orofacial region defects.

The aesthetics of the mouth corner area occupies an important position in maxillofacial aesthetics, and it also plays an irreplaceable role in daily activities such as facial expression movement and speech [10]. However, because the anatomical structure of the corner of the mouth is very complex and delicate, and often the defect will destroy the integrity of the orbicularis oris muscle, so compared with the repair of upper and lower lip defects, the repair of the corner of the mouth defect is a difficult point in lip repair, and it is very difficult to achieve the results that are satisfactory to both the patient and the doctor. The principles of reconstruction of the corner of the mouth are basically same as the lip defects, the first need is to obtain the desired appearance, and more importantly, to restore complete oral function [12, 27]. However, in previous reports on the repair of mouth corner defects, a particular method was often described and not much was done to compare the different repair modalities. We evaluated the functional and aesthetic outcomes after repairing oral angle defects using different adjacent tissue flaps and their modifications.

The Estlander flap was first described for reconstruction of oral commissure in 1872 [28]. As a method of lip defect repair, the Estlander flap is recognized as an ideal method for repairing moderate lip defects. However, the disadvantage is that it may affect the degree of opening [29,30,31,32,33]. The results of repairing the defect of the opposite side of the lip with the help of the normal tissue of one side of the lip are more satisfactory because of the consistent tissue anatomy, the coordinated proportion of the upper and lower lips, and the formation of a new corner of the mouth after rotation. At the same time, we prepared the Estlander flap by removing as much subcutaneous tissue as possible while ensuring the blood supply, resulted in a more thin preparation of the flap in contrast to the previous flap and reduced the bulkiness of the reconstructed area.The downside is that there may be a small mouth deformity along with the formation of the new mouth angle, which requires a later correction of the mouth angle opening. This may be due to the fact that the Estlander flap utilizes the contralateral lip tissue to repair the defect and does not increase the overall lip tissue, which results in a very limited amount of tissue available if the defect is large, and consequently, a small mouth deformity may occur. Considering that the Estlander flap is relatively simple to prepare and easy for beginners to use, and that it is a rotational flap that preserves the natural redness of the lip without turning the mucosa, which greatly reduces the difficulty of flap preparation, we believe that the Estlander flap can be the first choice for small and medium-sized commissure defects.

In 1983, MeGregor modified the typical Gillies flap and Karapandzic flap, which may cause micrognathia, by making the axis of rotation of the neighboring flap at the corner of the mouth, rotating the corner of the mouth in place, with no postoperative micrognathia. However, due to the 90-degree rotation of the adjacent flap, the muscle fiber orientation is changed, which affects the function of the oral movement to some extent [34]. To address this problem we previously innovated the preservation of the depressor anguli oris (DAO), and in a previous study the function of the oral movement was unaffected, and the risk of small mouth deformity was greatly reduced [14]. Follow-up results showed that the use of the MeGregor flap with preserved DAO to repair defects was aesthetically and functionally effective. In particular, the preservation of DAO allowed the patients’ ability to perform oral movements was not disrupted, and we believe that this method is an ideal way to preserve motor function in oral commissure reconstruction.

The design of the Fries flap is more suited to horizontally oriented defects, bending the skin incision upward to reduce tension near the corners of the mouth and ensuring that the slight increase in flap width does not make the newly reconstructed lips too short, and also allows the corners of the mouth to be located in their original position [15]. Depending on the position of the Fries flap at the time of design, it can be used to repair a wide range of oral commissure defects and is uniquely suited for the reconstruction of defects involving both the upper and lower lip.However, the skin incision is perpendicular to the skin tension line, which may result in a poorer appearance of the reconstructed area. At the same time, we found that the corners of the mouth did not close tightly, resulting in saliva spillage, which may be due to the fact that the corners of the mouth reconstructed by Fries were more rounded and blunt, resulting in a lack of sealing of the corners of the mouth.

In 1980, Fujimori reported the repair and reconstruction of total lower lip defects with the name “gate flap”, which is a nasolabial fold island flap [16]. Gate flap and its modifications have been widely used for upper and lower lip reconstruction [35]. Fujimori gate flap combined with the mucosal mesh method to address the need for repair of mucosal defects [36].Since the design of this flap involves more normal tissue than other flaps, the resulting scar will be longer and have a greater impact on the patient’s appearance, so this requires that the incision be placed as invisibly as possible during the intraoperative design of the flap to make good use of the natural facial folds. We have found that the blood supply to the reconstructed area is adequately ensured due to the preservation of the lacrimal artery, and the color of the reconstructed area is close to that of other normal areas after surgery.More importantly, the Fujimori flap, which repairs defects using tissue from the nasolabial folds, provides an adequate amount of tissue in the repair of larger defects of the upper lip, and is an appropriate repair if the corner of the mouth area involves a defect of the upper lip.

The Colmenero flap is an axial flap that utilizes the skin, muscle, and mucosa adjacent to the lower lip defect to provide tissue similar to that of the excised tissue [20].In 2000, Lopez et al. applied the Colmenero flap to repair a defect with a lateral width of two fifths to three fifths of the lower lip. This technique involves repairing the lower lip defect by taking a bi-dimensional musculocutaneous island flap with the labial and chin arteries as the blood supply on the lateral aspect of the lower lip defect [37]. In the three cases of defects that we repaired using the Colmenero flap, the irregularity of the scar in the reconstructed area was more severe relative to the other flaps. However, its use for repairing the corner of the mouth defects involving a larger area at the lower lip is well recognized.In addition, both cases reported more severe numbness in the reconstructed area at follow-up, and more cases are needed to investigate whether this is a common phenomenon.

The main limitation of this preliminary study is that the small samples of some of the repair modalities may reduce the accuracy of the results, even to the extent that the results are affected by individual cases, which raises the hope that further studies will continue to correct the results.

Conclusion

In this paper, we compare five common methods of repairing oral commissure defects. The McGregor and Colmenero flap are better at restoring oral motility. All reconstructive areas are in the normalization of speech and tactile sensitivity, with the appearance being guaranteed. Meanwhile, we believe that the Estlander flap can be used as the first choice for small and medium-sized commissure defects; our modified McGregor flap and Colmenero flap can be used for patients who require higher motor function; Patients with the Estlander, McGregor and Colmenero flaps have a higher level in quality of life. However, the clinician needs to analyze the specific problem and choose the most appropriate repair for patients, taking into account the extent and location of the defects.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

POSAS:

Patient and Observer Scar Assessment Scale

DRS:

Drooling Rating Scale

SCC:

squamous cell carcinoma

BCC:

basal cell carcinoma

DAO:

depressor anguli oris

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, No.117 Nanjing Bei Street, Heping District, Shenyang, Liaoning, 110002, PR China

    Xuewei Jia, Xiaomeng Xue, Fayu Liu, Pai Pang, Yang Yue, Menghan Li, Zhongzheng Qi & Changfu Sun

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  1. Xuewei Jia
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Xuewei Jia: Writing– review & editing, Writing– original draft, Methodology, Investigation, Conceptualization. Xiaomeng Xue: Conceptualization, Investigation, Writing– review & editing. Fayu Liu: Writing– review & editing, Investigation. Pai Pang: Methodology，Investigation.Yang Yue: Methodology，Investigation. Menghan Li: Methodology，Investigation.Zhongzheng Qi: Conceptualization, Investigation. Changfu Sun: Writing– review & editing, Conceptualization.

Corresponding authors

Correspondence to Zhongzheng Qi or Changfu Sun.

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Ethics approval and consent to participate

The study project was approved in advance by the Institutional Review Board of China Medical University (Shenyang, Liaoning, China, number: K2024040). All patients participating in the study were informed of the aim and process of the study prior to enrollment and signed an informed consent form. The research team solemnly declares its strict adherence to the principles established in the Declaration of Helsinki to ensure that the research is scientific, ethical and moral and that the rights and interests of the participants are fully protected.

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Not Applicable.

Competing interests

The authors declare no competing interests.

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Jia, X., Xue, X., Liu, F. et al. Functional and aesthetic evaluation of adjacent tissue flap repairing defects of oral commissure area. BMC Oral Health 25, 536 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12903-025-05924-4

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12903-025-05924-4

Keywords

BMC Oral Health

ISSN: 1472-6831

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