J OralMaxillofac Surg 68:664-667, 2010 Microsurgical Upper Lip Replantation: A Case Report Alessandro Baj, MD,* Giada A.Beltramini,MD,† Francesco Laganà, MD,‡ and Aldo B. Giannì, MD§ Lip amputation is rare, and systematic microsurgical replantation is necessary to achieve morphofunctional restoration of the traumatized structure in a single sur- gical operation. We describe a case of right hemilip and labial filter avulsion, resulting from a dog bite. The am- putated section was revascularized by arterial micro- anastomosis, whereas no venous anastomosis was per- formed, because no venous blood vessel was identified. Venous drainage was obtained through the postopera- tive application of leeches together with anticoagulant and antibiotic therapy. The esthetic and functional re- sults were good in terms of form, color, scarring, and the restoration of lip function and sensitivity. Traumatic lip amputation is rare, with only a few dozen reported cases. It often has devastating effects from esthetic, functional, and psychological perspec- tives. The most common causes of lip amputation are dog bites and human aggression. The upper lip is affected twice as frequently as the lower lip. Consid- ering the available reconstruction methods, standard nonmicrovascular lip replantation procedures often do not ensure sufficient functional and esthetic resto- ration and local tissue is frequently sacrificed. 1,2 Ad- vances in microsurgical techniques allowed James 3 to perform the first successful lip replantation, in 1976, in a child with nasolabial amputation caused by a dog bite. We describe upperlip replantation in a patient after traumatic avulsion caused by a dog bite carried out at the Department of Maxillo-Facial Surgery of the Galeazzi Orthopedic Institute in Milan, Italy. Report of a Case A 32-year-old woman was admitted to the accident and emergency unit, with lip amputation caused by a dog bite (Fig 1). The amputated segment consisted of a 2.5 ⫻ 3– cm mucosaland myocutaneous flap, comprising the upper right hemilip and labial filter (Fig 2). The amputated section was preserved in a hypothermic state. The patient had no other injuries as a result of the dog attack. An emergency replantation operation was undertaken. First, the stumps of the severed labial artery were isolated on the amputated segmentand patient’s lip. Revascularization was accom- plished by arterial microanastomosis with the correspond- ing labial coronary artery (Fig 3). The arterial microanasto- mosis was performed immediately to revascularize the amputated lip segment as soon as possible. It was hoped that this procedure would also facilitate the identification of any venous outflow in the flap. Unfortunately, because of the tearing effects of the trauma, no vein thatcould be considered suitable for microanastomosis was found. The arterialmicroanastomosis was carried out with No. 10.0 nylon.The lip was deliberately stitched loosely to allow bleeding.The ischemia time was approximately 6 hours. The operation lasted 3 hours. Because no venous anastomo- sis was possible, venous drainage was accomplished by the postoperative application of medicinalleeches(Hirudo medicinalis) for 12 days: every 2 hours on average for the first 6 days and then every 5 hours from the seventh day onward ( Fig 4). The patientwas also given intravenous gentamicin, 80 mg 3 times a day, for 5 days, and metroni- dazole, 500 mg once daily, and cefazolin, 1 g 3 times a day, for 8 days. Anticoagulant therapy with nadroparin, 0.2 mL, was administered for the first 8 postoperative days. This was then combined with oral acetylsalicylic acid, 100 mg daily, for the next 9 days and then acetylsalicylic acid alone until discharge from the hospital and for a further 30 days at home. Seven bags of packed red blood cells were transfused postoperatively to compensate for the blood loss caused by the application of leeches. The patient spent 18 days in the hospital. At 24 months postoperatively, the esthetic results were satisfactory in terms of form, skin color, and wound healing, with vermilion correction performed by a little cross-lip flap (Figs 5-7). From a functional perspective, adequate restora- tion of stomalcontinence and mobility of the orbicularis oris muscle were achieved. The Weber test indicated that sensitivity was rehabilitated to a 2-point discrimination of 6 mm. Received from the Department of Maxillo-Facial Surgery, Istituto Ortopedico Galeazzi, University of Milan, Milan, Italy. *Chief Assistant. †Resident. ‡Chief Assistant. §Professor and Chief. Address correspondence and reprint requests to Dr Baj: Depart- ment of Maxillo-Facial Surgery, Istituto Ortopedico Galeazzi, Univer- sity of Milan, via Riccardo Galeazzi 4, Milan, Italy; e-mail: alessandro. baj@unimi.it ©2010 American Association of Oral and Maxillofacial Surgeons 0278-2391/10/6803-0029$36.00/0 doi:10.1016/j.joms.2009.07.028 664 MICROSURGICAL UPPER LIP REPLANTATION