The delayed mouth-opening technique: a staged inset strategy to prevent distal necrosis in perioral free flap reconstruction.

PURPOSE: Severe perioral scarring from thermal injuries causes profound functional deficits. Circumferential free flap reconstruction risks distal ischemia upon acute oral aperture creation. This study evaluates a novel staged inset protocol using pre-expanded internal mammary artery perforator (IMAP) flaps to mitigate distal necrosis risk.

METHODS

A retrospective case series reviewed 12 patients with severe perioral scar contractures who underwent tissue expansion (Stage 1), scar excision and flap transfer with temporary 1- to 2-cm microstoma creation (Stage 2), and delayed definitive commissure division after 2 to 4 weeks (Stage 3). Outcomes included interincisal distance, dietary status, oral competence, patient satisfaction (Visual Analog Scale, VAS), and scar quality (Vancouver Scar Scale, VSS).

RESULTS

All primary facial flaps survived, with no distal necrosis. One primary facial flap required early re-exploration for venous thrombosis but was successfully salvaged. The mean interincisal distance improved from 15 mm preoperatively to 40 mm at a mean follow-up of 11.8 months. Preoperative drooling (n = 3) and dietary restrictions to liquids/semi-liquids (n = 3) were completely resolved. The mean VAS score was 8.3 ± 0.8, and VSS scores ranged from 2 to 4.

CONCLUSION

The delayed mouth-opening protocol achieved complete flap survival, objective functional restoration, and favorable aesthetic outcomes, offering a highly reliable strategy to prevent distal necrosis in severe perioral reconstruction.