Evaluation of a Fascial Sling Technique for Primary Modiolus Reconstruction to Preserve Lip Symmetry Following Head and Neck Free Flap Surgery: A Preliminary Report

BACKGROUND: Modiolus loss after ablative head and neck surgery can result in oral incompetence, commissure deviation, and poor facial symmetry. Although fascial suspension for perioral reconstruction has been described, the value of incorporating primary modiolus reconstruction into free flap surgery has not been well defined. This report evaluated the feasibility and postoperative outcomes of primary modiolus reconstruction using a fascial sling. METHODS: We retrospectively reviewed 13 patients who underwent unilateral primary modiolus reconstruction during head and neck free flap surgery between June 2010 and August 2024. Fascia harvested from the flap donor site was inset in a Y- or V-shaped configuration to suspend the upper and lower lips from the masseter muscle. Outcomes included commissure deviation at rest and during mouth opening evaluated using a quantitative photographic method, flap- and donor-site complications, commissure ptosis, and diet. RESULTS: Thirteen patients with a mean age of 72.5 years (range, 61-86 years) underwent reconstruction; 11 had buccal mucosal carcinoma; 1, lower lip carcinoma; and 1, accessory parotid gland carcinoma. All the patients underwent ALT flap reconstruction; the fascial configuration was Y-shaped in 10 patients and V-shaped in 3 patients. Eleven patients were evaluable at least 6 months postoperatively. At rest, seven patients showed no commissure deviation and four showed mild deviation. During mouth opening, 10 patients were evaluable: 7 showed no deviation; 2, mild deviation; and 1, moderate deviation; no patient showed severe deviation. No flap-related or donor-site complications or postoperative commissure drooping were observed. Four patients resumed a regular diet; five, a soft diet; and four, a pureed diet. CONCLUSION: Primary modiolus reconstruction may help preserve oral commissure position and symmetry, with a low risk of procedure-related complications. Considering survival outcomes, technical advantages, and surgical invasiveness, performing modiolus reconstruction at the time of the initial surgery may be clinically meaningful.