Functional and Aesthetic Restoration of Total Lower Lip Defects Using the Radial Forearm Free Flap

Abstract: Total lower lip reconstruction presents a significant surgical challenge due to the need to restore oral competence, dynamic mobility, and facial aesthetics. While local and regional flaps are often insufficient for extensive defects, free tissue transfer remains the gold standard. The radial forearm free flap (RFFF), owing to its thin, pliable, and well-vascularized tissue, is particularly suited for complex lip reconstructions. We report the case of a 40-year-old male with a history of chronic smoking and previously treated squamous cell carcinoma of the lower lip. Following wide local excision, a through-and-through defect involving the entire lower lip and both oral commissures was reconstructed using a folded radial forearm free flap. The flap was harvested from the non-dominant forearm and inset to recreate both the mucosal and cutaneous lip surfaces. Microvascular anastomoses were performed to the facial and external jugular systems. Functional outcomes included restoration of oral competence, adequate mouth opening, and intelligible speech. Aesthetic results were rated as good to excellent, with minimal donor site morbidity. Despite the increasing use of anterolateral thigh (ALT) flaps in oropharyngeal reconstruction, the RFFF remains superior in scenarios demanding fine tissue pliability and structural resilience. Its reliability in double-layered reconstructions and ability to contour complex three-dimensional structures make it particularly effective in total lip reconstruction. However, biological limitations such as lack of native muscle innervation and skin color mismatch persist. The RFFF continues to represent a safe, effective, and versatile solution for total lower lip reconstruction, particularly in cases requiring pliable tissue and precise anatomical restoration. Long-term outcome studies incorporating patient-reported measures are essential to further refine reconstructive strategies and improve functional and aesthetic satisfaction.