Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Reconstruction of the Oral Commissure With the Use of a New Technique: The Asterisk Design Alper Sari, MD, Alper Aksoy, MD, Yavuz Basterzi, MD, and Sakir Unal, MD Abstract: Microstomia reconstruction due to the presence a blunted oral commissure is a challenging task because it requires the restoration of intricately balanced distinct layers of tissues: the oral mucosa, the orbicular muscle, the vermilion border, and the perioral skin. The reliability of commissural reconstruction depends on 2 factors: the first one is breaking the contraction vectors causing blunting of the commissure and the second one is restoring the in- tegrity of the oral sphincter. We have used local skin, vermilion borderYmuscle, and mucosa flaps designed in an asterisk pattern to break the contraction vectors and have paid certain attention to the restoration of the sphincter function of the circular muscle fibers. Our results have shown that, with the use of our asterisk design, a new commissure aesthetically comparable to the natural one can be created with the reestablishment of reliable oral competence. Key Words: Oral commissure, microstomia, oral sphincter, oral competence (J Craniofac Surg 2009;20: 1256Y1259) S car contractures caused by facial trauma and burn injury as well as blunt commissural angles caused by flap reconstructions after perioral tumor surgery may destroy the unique architecture of the oral commissure and may lead to microstomia. Reconstruction of the perioral region necessitates certain skills and a good knowledge of facial anatomy. The multilayered complex structure formed by the perioral muscles, vermilion borders, oral mucosa, and skin must be imitated in a commissure reconstruction. As in every type of reconstruction, the golden rule is to use the most alike tissue to replace the missing one. When dealing with oral commissure reconstruction, the contraction vectors causing blunting of the commissure and the restoration of the integrity of the oral sphincter must both be adequately addressed. Bearing these 2 factors in mind, we have developed a technique with the use of local pericommissural tissues containing skin, subcutaneous tissue, muscle, and mucosa to reconstruct the oral commissure and to correct microstomia. MATERIALS AND METHODS Within the period from 2005 to 2008, we used the asterisk flaps in 6 patients to reconstruct the deformed oral commissures and to correct microstomia. Surgical Technique First, the exact location where the new mouth corner should be placed must be decided based on the distance measurements made between the Cupid’s bowand the oral commissure on the nor- mal side. In cases with bilateral commissural deformities, the new mouth corners should be marked at both sides lateral to the de- formed ones, paying attention to the equivalence of the distance between the Cupid’s bows and the oral commissures on 2 sides. In the next step, a skin incision was designed in the shape of an as- terisk with its horizontal leg starting at the new commissure point laterally and running medially through the scarred skin and ver- milion border up to the mucosal border (Fig. 1A). The horizontal skin incision must leave the underlying orbicularis muscle fibers intact if they were preserved during initial trauma or surgical attempts. The oblique incisions at the vermilion skin border were performed in a full-thickness manner (including the muscle fibers and mucosa underneath) to free 2 muscle-containing vermilion flaps: one is based superiorly and the other is based inferiorly. The laterally divergent extensions of the oblique incisions were kept at the skin level exposing the underlying lateral portions of the orbicularis muscle. As these incisions were completed, 4 tri- angular skin flaps should be formed. Skin flaps Ba[ and Bb[ were elevated above the muscle layer, whereas the other 2 flaps lateral to flaps Ba[ and Bb[ were kept to be excised at the next step of the procedure. Once the orbicularis muscle was exposed, the most medial part of the muscle remaining beneath the scarred tissue was carefully incised horizontally for a couple of millimeters without injuring the underlying mucosa (Fig. 1B). The preserved mucosa under the muscle should be used for the creation of a posterior-based mucosal flap in the next step. The amount of muscle release should be decided based on the need for the enlargement of the oral stoma. The incised medial muscle fibers should be carefully sutured to the more lateral fibers that were kept intact with an aim to increase the strength of the sphincter. A posterior-based triangular mucosal flap was then designed with its tip at the mucosa-skin junction (Fig. 1C). As this flap was rolled outward around the remaining intact muscle fibers and advanced laterally, its tip should be sutured to the new commissural point (Fig. 1D). In the next step, the previously created lateral triangular skin flaps were excised to leave enough advancement space for flaps Ba[ and Bb[ (Figs. 2A, B). Skin flaps Ba[ and Bb[ and the superior and inferior vermilion flaps Bv[ were then advanced laterally and sutured to the new commissural point and the previously advanced mucosal flap in a sequential manner (Figs. 2C, D). The muscle fibers within the vermilion flaps must be separately sutured to the opposite ones at the new commissural point. TECHNICAL STRATEGY 1256 The Journal of Craniofacial Surgery & Volume 20, Number 4, July 2009 From the Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Mersin University, Mersin, Turkey. Received January 14, 2009. Accepted for publication April 8, 2009. Address correspondence and reprint requests to Alper Sari, MD, Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Mersin University, Zeytinlibahce Caddesi, 33069, Mersin, Turkey; E-mail: dralpersari@yahoo.com Copyright * 2009 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3181acdfc7