Professional Documents
Culture Documents
Lip Reconstruction
Lip Reconstruction
LIP FUNCTIONS
1. Oral competence
2. Deglutition
3. Speech
4. Express emotion
5. Beauty
Surgical Considerations
VERMILLIONECTOMY
Indicated for severely dysplastic or SCC-insitu involving the majority of the lip
Lip shave procedure
Mucosal advancement (with underlying glands and muscle) will improve fullness
Others have advanced the mucosa as a bipedicle flap and letting the raw area in the sulcus heal by
secondary intention
Drawbacks of mucosal advancement
1. Vermilion becomes thin and the vestibule becomes shallow. This can cause food spillage during
eating
2. loss of lip pout
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3. The tense free lip margin pulled in - inward drawing of hair at the junction, creating a source
of irritation – in men especially may require thinning of skin flap to remove hair follicles
4. Dryness and edema. Dryness and keratotic changes of the mucosal flap are thought to stem from
histologic differences between oral mucosa and the vermilion
VERMILLION-ONLY DEFECTS
Wedge excision
Mucosal advancement
o VY
o Bipedicled from sulcus or opposite lip
o Notch or whistle deformities may be corrected by excision and Z-plasty.
o Tezel
lies just below the parotid duct opening and extends to the retromolar trigone.
consists of mucosa, submucosa, and muscle only under the proximal 1.5 to 2 cm of the
random flap.
Up to 3x6 cm, can cover near total defect. Donor defects of the flaps in cheek mucosa up
to 3 cm wide can be closed primarily.
Bilateral flaps can be used- one to resurface the vermilion defect and the other one
covering the inner side of the lip
FAMM flap
Tongue flap
o If labial or buccal mucosa not available
o less than ideal because of a definite color mismatch with normal lip vermilion.
o usually left attached for 2 weeks before division and inset.
o In males the papillary surface to the tongue can be used, but in women it is recommended that the
undersurface is used as it is smoother.
o Free tongue composite grafts for small vermilion defects have been described.
Grafts
o Full thickness palatal mucoperichondrial graft
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1. take well and contract minimally, but are placed only behind the wet-dry line because of their
very poor color match with the vermilion.
o Labia minora graft
o Composite skin cartilage graft for philtral reconstruction
Two commissure-based buccal mucosal flaps can be used for gingivobuccal sulcus reconstruction: one of the flaps is
used to resurface the gingiva and the contralateral flap is used to cover the inner surface of the lip. (Right) Lateral
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section of sulcus reconstruction by two commissure-based buccal mucosal flaps. Note that the suture between the two
flaps also passes through the periosteum of the mandible to create the depth of the sulcus.
Direct Closure
Defects up to 25% (30% in the elderly)
often necessitates removal of perialar crescents to facilitate
medial movement of the native labial edges.
Best for lateral subunit; repair of periphiltral defect in the
upper lip distort the philtrum. This effect decreases as the
resection occurs more laterally.
Philtral (medial) defects may remove cupid’s bow giving the
lip a flattened appearance. Thus an Abbe flap or full-
thickness skin graft may be a better choice.
Nasolabial Flap
Nasolabial flaps for lateral upper lip deficiencies look good at rest,
but the transverse scar is exacerbated during smiling. In addition,
these look strange in men whose hairless flap contrasts with the
hair-bearing lip.
Combined with mucosal advancement
Central Defects
Abbe flap
Original description was for reconstruction of bilateral cleft lip
(Robert Abbe 1898)
Traditionally the Abbe flap is designed to be approximately half as wide as
the defect.
With the subunit principle, Burget and Menick excises the entire
subunit if defect involves most of it and reconstructs with a lower
lip Abbe of the same size
Millard states that Abbe flap may survive by mucosal bridge alone
Spontaneous reinnervation of the reconstructed lip within 1 year of
surgery.
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Commisural defects
1. Reverse Estlander flap
Lateral Defects
1. Lip-switch flap (Abbe)
Repair up to 50%
3. Nasolabial flaps
Central Defects
Lip switch flap(Abbe flap)
The lower lip can easily sacrifice 25% to
35% of its length without significant functional or cosmetic impairment.
Nasolabial flap
1. Von Brun’s NL flap
2. Bilateral levator anguli oris flap
a. Combined with Abbe flap for total upper lip reconstruction
3. Converse superiorly based NL flaps
Free Flaps
Have been used for total reconstruction
Upper lip functions more like a hanging drape and can be more appropriately reconstructed by an
adynamic flap, such as the radical forearm free flap.
Burget makes a point that only the Abbe flap realigns the skin,/muscles correctly:
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Need to decide whether to use remaining lip tissue (and therefore reduce oral diameter or circularise the
fissure)
largest defect of the lip that can be repaired with remaining lip tissue is usually about 66% to 75% (more
in elderly patients with lax lips)
For repair of very large defects of the lower lip, there are two main approaches:
1. using only local tissue cheek advancement variants such as Webster–Bernard flaps
2. circularization procedures such as the Karapandzic neurovascular flap technique.
2. bilateral rectangular flaps from the labiomental area together with bilateral buccal mucosal flaps for
vermilion reconstruction (Owen)
The steps are designed asymmetrically with shorter horizontal limbs on the side of the defect
The drawbacks occur if the defect is large:
1. the lip might end up tight.
2. the scars may be visible
The advantages are:
1. relatively good sensation is maintained
2. muscle continuity and function are usually maintained
3. the procedure can be adjusted for lateral lip defects
4. can be used in conjunction with other techniques
Two stage procedure usually. A third stage may be necessary to equilibrate the vermilion.
The tissue is initially denervated, but in follow-up, sphincteric function returns.
o return of normal EMG amplitude by 1 year, and of pain, touch, temperature, and
sweating responses by 2 years.
o 60% to 70% of the original muscle function reestablished.
Flap design and transfer –
Medial incision on the philtrum ridge - closure on natural landmark but the philtrum may
shift.
Maximum size of flap design ~ 2 cm (25% of average length of upper lip)
The width of the flap usually half the length of the defect
Excision of Burrow’s perialar crescents will provide an excellent aesthetic result.
The flap should be dissected to a narrow vermilion pedicle on the inside of the lip.
artery and its vein course just beneath the mucosa on the lingual aspect of the lip at the level
of the mucocutaneous junction.
Flap is pedicled medially or laterally and the remaining upper lip segment must be advanced
medially to close the donor site defect. Medially based Abbe allows wider mouth opening as
places the pedicle more laterally
The flap can be square or tapered into the nasolabial fold
The location of the artery is noted when the incision is made on the nonpedicle side of the flap
so that it is not injured when dissecting the pedicle side of the flap.
The donor site usually heals with minimally visible scars, but the lip may feel tight.
The flap inset is usually performed after approximately two weeks.
Often requires secondary surgery owing to the mild discrepancies between the transferred lip
vermilion and the vermilion in the area of inset.
Note not to island the flap on the artery alone - very important to keep strip of mucosa. More
likely to get flap survival if flap islanded on the mucosa than on the artery
Modifications
Kazanjian’s extraphiltral cross-lip flaps.
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Ashley’s procedure
Local flaps
Estlander
Full-thickness, medially based, triangular upper lip flap including commissure.
Secondary revision is needed to restore the sharp angle at the corner of the mouth.
Designed directly opposite the wound (adjoining the commissure) – ½ width
Vascular pedicle is within pivot point (from opposite labial artery)
Distorts commissure and modiolus, thus may alter oral animation
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The proper muscular direction is maintained and the lip sphincter is restored to prevent drooling,
with an adequate labial sulcus.
Main disadvantage is microstomia – requires secondary comissurotomy in 25%
Needs regular stretching exercises, and some require prosthesis
Method
Vertical height of defect determines the width of the flap
Width maintained circumorally
Some surgeons advocate placing the incisions in the nasolabial fold, but it is acceptable to create
semicircular incisions from the defect that ignore the folds.
Incisions are full thickness thru skin,muscle, mucosa medially
selective lysing of specific suspensory muscles to allow lip movement
Laterally at level of commissure, subcutaneous incision only
Preserve labial vessels and buccal nerve branches
If central, move both flaps equally for symmetry
If unilateral, more advancement must be obtained from contralateral lip to minimize upper lip
distortion
3 layered closure
Extended flap using lower lip segments have been described for total reconstruction
McGregor flap
Further modified the Estlander flap with the inclusion of vermillionectomy
Like the Gillies fan flap the McGregor modification contain the superior labial vessels.
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The rectangular McGregor modification, in contrast, pivots around the commissure, transposing the cut
edge upward.
Advantages:
1. Maintains intercomissure distance - no microstomia
Disadvantage
1. New vermillion necessary - a tongue flap or mucosal advancement, which is used both to resurface
the free edge of the flap and the remaining lower lip.
2. Changes the direction of the muscle fibers and thus decreases the strength of sphincteric action.
3. Denervates the motor and sensory supply of the flap, therefore one expects more drooling.
(McGregor however, claimed that the sensory loss was negligible and that recovery of function did
eventually occur.)
Nakajima modification maintains the facial vessels supplying the flap.
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Bernard-Burow Procedure
original design included excision of full-thickness tissue triangles above the lateral cheek segments
Original Bernard design for lower lip reconstruction Original von Burow design for upper lip
Webster modification
additional labiomental triangles
Excised triangles are skin and subcutaneous only
primary cheek incision begins at the border of the defect and
continues laterally for a distance that equals one half of the
defect’s width
nearly full-thickness incision, stopping just short of the
mucosa, which is cut about 5 to 10 mm higher.
‘‘vermilion’’ of the reconstructed lip comes from cheek
intraoral mucosa that is cut more superiorly than the
horizontal skin incision, allowing the mucosa to roll out and
meet the cheek skin.
Lower skin incisions are made along the labiomental crease
to release the lateral cheek elements and allow medial
movement.
Muscular attachments of the cheek elements to the mandible must be released, or there will be little
movement.
ideal in older patients, because cheek laxity is often present.
a net gain of lip tissue, and microstomia is usually not an issue.
Disadvantages:
1. The gingivobuccal sulcus created by this approach is often inadequate and may need to be
deepened with revisional surgery.
2. There is often a shortening of the vertical scar, and it is not uncommon to end up with a notched
lip at the center of the reconstruction
3. The ‘‘vermilion’’ part of the reconstruction often rolls backward over time, reducing the aesthetic
outcome.
4. Poor muscular function - ability of a reconstruction with cheek advancement to prevent drooling
is probably related more to achieving the correct passive tightness of the lip across the lower teeth
and mouth.
Nasolabial flaps
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o
Fujimori gate flap
o inferiorly based nasolabial flap that is closed in a staggered line fashion
o can also be transferred as full-thickness arterialized nasolabial island flaps and tunneled to the
lower lip
o should be used for total lower lip reconstruction, since they tend to sacrifice less normal tissue
than the usual Bernard-Burow procedure
o for smaller reconstructions, Bernard procedure gives nicer results
The reconstructed lip is usually a block of tissue that is immobile and insensate, serving as a dam
rather than as a dynamic structure.
Effective reconstruction of the lower lip requires not only skin and mucosa, but also functioning
muscle.
Double Abbe
Medially based switch flaps sutured to each other in the lower lip midline and are left attached for
three weeks.
Based on columella/septal branch
The final result is satisfactory and the comissures are preserved
Bilateral Karapandzic
Webster Bernard
Bilateral McGregor
Regional flaps
1. Submandibular flaps
2. superiorly based anterior cervical flap
3. axial buccinator musculomucosal flap based on the buccal artery.
4. FAMM flap (Probaz PRS 2000)
consists of the mucosa, submucosa, a small amount of buccinator muscle, and a more deeply
lying facial artery and venous plexus.
Different from buccinators flap in blood supply and orientation of flap
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may be used as a superiorly based flap, which is perfused in a retrograde manner by the
angular artery, a continuation of the facial artery; it may also be based on the superior labial
branches and other anastomotic branches from the infraorbital vessels
The flap may also be based inferiorly on the facial vessels as they enter the face at the anterior
edge of the masseter muscle
5. sternocleidomastoid musculocutaneous flap
6. deltopectoral flap
last 2 associated with significant donor defects
Free flaps
Most useful where there is involvement of adjacent tissues (ie chin)
Free radial forearm flap
palmaris longus tendon may be harvested for sling support
Sometimes the palmaris tendon interferes with the course of the vascular pedicle and therefore
must be separated from the flap and routed separately.
Some surgeons advocate securing the tendon ends to the maxilla, whereas others are satisfied with
strong attachment to the ends of the modiolus, or even to remnants of the upper orbicularis
muscle.
When folded, the cutaneous island can double for lining and cover in the reconstruction; oral
competence is good.
Blending with muscosal flaps give better results – the lining part of the flap can be
deepithelialised and surfaced with advanced mucosa or FAMM flap
Secondary commisuroplasty is often required
Other free flaps that can provide this pliable tissue for lower lip reconstruction include the scapular flap,
lateral arm flap, anterolateral thigh flap, and groin