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Lip Reconstruction
Lip Reconstruction
LIP FUNCTIONS
1. Oral competence
2. Deglutition
3. Speech
4. Express emotion
5. Beauty
Surgical Considerations

LA v's GA – Infraorbital Nerve/Mental Nerve blocks

Landmarks – Mark the white roll prior to injection of local anesthesia and make elective incisions
perpendicular to the vermilion skin junction

Microstomia
o
May require considerable postoperative lip stretching by appliances
o May require dentures constructed especially to collapse during insertion or removal.
o Dentulous patient must be able to open mouth enough for access for dental repair.

Meticulous muscle repair when applicable is always required.

Use of full-thickness nasolabial tissue may denervate the upper lip. Reduced sensation in addition to poor
sulcus depth may result in drooling, (more common after lower lip reconstruction). Deepening of the
vestibular trough, repositioning of the frenulum and broadening of the gingiva may be required.
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.

Arterialized vermilion musculocutaneous flap

Commissure based buccal mucosal flap
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o Rayner and Arscott - 1cm wide flap based at the angle of the mouth, and distal ends just below the
parotid duct. Raised with buccinators muscle along entire length
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
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
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o Composite skin cartilage graft for philtral reconstruction
Gingivobuccal Sulcus Reconstruction

Traumatic or postoperative loss of the gingivobuccal sulcus
1. restrains lip mobility
2. causes inward displacement of lip
3. limits the use of tooth prostheses.
4. loss of gutter – food spillage

Repair of the gingivobuccal sulcus is one of the most important parts of lip reconstruction.

Skin graft unsatisfactory
o Pressure must be put on the grafts for at least 5 days by special molds that often cause
maceration, odor, and discomfort for the patient.
o secondary contraction of the graft is a nearly inevitable outcome

Local flap options best:
o FAMM flap
o buccal musculomucosal flap
o Terzel’s The commissure-based buccal mucosal flap
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
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.
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Upper Lip Reconstruction
Vermilion Defects of the Upper Lip

Small excisions should be kept within the vermilion (vertical or horizontal vermilion ellipse).

Larger defects may require a mucosal V-Y advancement flap.

Placement of sutures exactly into the white roll in both the upper and lower lips should be avoided,
(subsequent redness associated with normal healing tends to blend with the vermilion, making the
mucocutaneous junction indistinct.)

When deficits of vermilion and muscle are present, the use of local tissue is preferred.

Slight whistle or notching defects, or defects wherein more upper lip tubercle might be desirable, may be
corrected by mucomuscular advancement flaps or simple V-Y advancement of the upper buccal mucosa.

Larger defects of vermilion and muscle may require flaps from the lower lip (Kawamoto flap, Abbe flap),
or tongue.
Defects < 30% of Upper Lip

Goals include the correct alignment of the vermilion and the
white roll and the reapproximation of the orbicularis oris
muscle.
Lateral Defects
Direct Closure

Defects up to 25% (30% in the elderly)
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
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.
Defects > 30% of Upper Lip
Commisural defects
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1. Reverse Estlander flap
Lateral Defects
1. Lip-switch flap (Abbe)

Repair up to 50%
2. Cheek advancement flap
i. Bernard Burrow
3. Nasolabial flaps
4. Oral circumference advancement
i. Unilateral Karapandzic
ii. Reverse fan flap
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.
Cheek advancement flap
1. Bernard Burrow
2. Webster combination flap
 not sufficient for total upper lip reconstruction.
Oral circumference advancement
1. Bilateral Karapandzic
a. Advantages- preserves motor and sensory
b. Disadvantages- microstomia, extensive
circumoral incisions and dissection
2. Reverse Fan flap
Nasolabial flap
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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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Reconstruction of upper lip hair bearing skin
Options
1. unipedicled submandibular neck flap
2. bipedicled submental bridge flap
3. temporal island scalp flap
o a temporoparietal fascia flap with a cutaneous island at the vertex of the skull
o extended 2-3cm past midline for total upper lip reconstruction
o pivot point at tragus
o tunneled under cheek
4. free scalp flap based on the occipital artery.
Lower lip reconstruction
Goals – Reconstructed lip should;
1. be sensate
2. maintain sphincter function
3. approximate to upper lip vermillion for watertight closure
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4. to create a dam to contain saliva and food
5. allow sufficient opening for food and dental care
6. Be of acceptable aesthetic appearance- slightly more prominent than upper lip with some semblance
of vermilion
The procedure often results in a tight, inverted lower lip that retrudes beneath the upper lip.
Reconstructive Hierarchy for lips
1. The remaining lip segment
2. The opposite lip
3. The adjacent cheek
4. Distant site
 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.
Defects < 30% of lower lip
Direct closure
 Up to one-third of the lower lip can be resected and closed directly without undue tension.

If excision will cross the mental crease, a more acceptable scar is obtained by modifying the V into a
splayed W, (single, or double-barrel)

Careful attention must be directed to the repair of the orbicularis muscle.

Accurate alignment of the mucocutaneous ridge (white roll) at each edge of the proposed resection
can be achieved if “tattooed” with methylene blue.
Grafts

small composite grafts from one lip to the other (maximum width 1.5 cm, average 1 cm),
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Defects 30-65% of lower lip
From same lip
1. VY advancement of bipedicled orbicularis oris musculocutaneous flap and advancement flap of labial
mucosa (Hagerty)
2. bilateral rectangular flaps from the labiomental area together with bilateral buccal mucosal flaps for
vermilion reconstruction (Owen)
3. Staircase or stepladder technique (Johanson et al, 1974)

Closure of lip defects of up to 2/3 of the lower
lip might be possible.

In larger lesions the step method can be
combined either with a fan flap or an Estlander
flap

The horizontal length of the step excision
measures one half the width of the defect thus
usually 2-4 steps required
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
vertical dimension of each step is 8–10mm

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
From Opposite lip
Most reconstructive techniques that use upper lip tissue will yield an excellent result
1. Schuchardt Flap (1954)

The barrel-shaped incision may be extended all the way
around the labio-mental fold(s) and the original
procedure described excision of submental triangles to
allow rotation-advancement of the lateral lip / cheek
elements.
These triangles need not be excised but a
cresentic excision around the labio-mental fold may be
of more use.

May be done unilaterally or bilaterally and may be
combined with an Abbe flap.

A 40 to 50% central lower lip lesion may be closed in this way.

If the defect is larger, the lip will be too tight
2. Reverse Abbe Flap

Transfers upper lip tissue pedicled on the labial artery.

The central part of the upper lip should never be used for donor tissue, as the philtral columns
and dimple are irreplaceable. A flap from the junction of the middle and lateral thirds of the
upper lip should be used. .
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
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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Gillies fan flap

Extended version of the Estlander flap, enlarged to include tissue lateral to the corner of the mouth

For total or near total reconstruction

Carries the commissure and lower lateral lip inward for the more medially located lower lip defect

The flap rotates into position with the resected lip margin sutured to the residual medial lip.

Like the Estlander procedure, the resulting commissure is distorted and the lower lip is shortened
(microstomia)

preserves continuity of at least a portion of the oral sphincter, which has a chance of functional return
through neurotization even though it has been denervated.

Complications: sensory loss, motor denervation, and vermilion deficiency.
Karapandzic Flap (1974)

Karapandzic modified the Gillies fan flap to reconstruct 3.5–7 cm central lower lip defects (80%)

neurovascular supply is left intact and the myocutaneous flaps are rotated medially, providing a
functional lower lip.
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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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
Von Brun (1857)
o prototype design for lip reconstruction with nasolabial flaps
o Pivoted on the commissures
o Taking muscles denervates the upper lip and destroys the orbicularis muscle at the commissure.
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

Rudkin (PRS 2003)
o questionable belief that muscle must be transferred into the defect to maintain oral competence
o Subcutaneous random nasolabial flap
o Bilateral used where 1 side is used for lining
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Defects > 65% of lower lip

Satisfactory functional reconstruction of total lower lip defects remains elusive.
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
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
Total lip Reconstruction
Local tissue available:
1. bilateral cheek advancement
2. bilateral nasolabial flaps
3. bilateral oral circumference advancement
Local tissue not available:
1. distant flaps
2. microvascular flaps (including hair-bearing flaps in males)
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