Lip Reconstruction -- Part II

 Updated 3/2017 --photos and all links removed (except to my own blogpost) as many no longer active and it was easier than checking each one.

Refer back to Lip Reconstruction -- Part I for the basic information and history. As with the smaller, non-full thickness defects, symmetry should be strived for with as little disturbance of the surrounding anatomic features as possible. Keep in mind the subunits of the lip and landmarks (white roll, philtrum, etc).

Small full-thickness defects of both the upper and lower lip can usually be treated with wedge excision and primary closure (less than a fourth to a third of the total lip missing).

For optimal cosmetic and functional results, full-thickness lip resections should be repaired in 4 layers.

• First, the submucosa is repaired by using a small-caliber (5-0), soft, nonirritating suture such as silk or Vicryl. The knots should be buried to prevent irregular wound contours and suture spitting.
• Second, the orbicularis oris is repaired by using an absorbable suture (4-0 or 5-0) such as Vicryl, Dexon, or PDS. Careful and meticulous reapproximation of the orbicularis oris is necessary to maintain competence of the oral sphincter.
• Third--realign the vermilion-cutaneous border with an epidermal vertical mattress suture prior to proceeding with the dermis/subcutaneous layer of the cutaneous lip. Proper and exact restoration of this border is crucial for a good aesthetic outcome. At the risk of being redundant, even a 1 mm discrepancy in the outline of the white roll is noticeable at a distance of 3 feet (Zide).
• Fourth, the skin is closed with a monofilament suture, taking great care to maximally evert the wound edges to prevent a depressed and noticeable scar. Small-caliber 5-0 or 6-0 sutures are preferred in this area.

RECONSTRUCTION OF Large Full-Thickness Defects

Upper lip reconstruction is guided by the need to provide a central philtrum and two lateral elements.

Subtotal central defects are best addressed by advancement of lateral elements carrying the orbicularis oris sphincter into an Abbe-Sabattini flap philtral reconstruction.

• Abbe-Sabattini Flap -- First record of this flap belongs to Pietro Sabattini (1838). Gurdon Buck used a cross-lip lap during the Civil War, but it wasn't until 1898 when Robert Abbe pulished his "new plastic operation" that other surgeons took note and named the procedure after him. It is good for replacement of one third to one half of the upper or lower lip. It allows for immediate reconstruction and will give continuity to the oral stoma (mouth). The donor site is closed primarily. The patient must be cooperative as the two lips will be temporarily "connected" until the flap is divided at a second procedure 10-14 days later.

• Reverse Fan Flap -- The flap is based inferiorly rather than superiorly. With the fan flap the lip may have some sensation, but muscular function may be compromised.

• Webster's Combination procedure adds a cross-lip lap to form the philtrum.

• Von Bruns's Nasolabial Flaps (1857) --the flaps are inferiorly based and pivoted on the commissures. The mucosa lining the flaps is later everted to form the vermillion. There are variations of this flap by Fujimori, Gurel, Mavili, and Meyer.

• Karapandzic's Inferiorly based Orbicularis Rotation Flap or Reversed Karapandzic Flap-- This innervated orbicularis oris flap was described in 1974 by Karapandzic and is often called by that eponym. It is composed of the orbicularis oris muscle with vermilion, overlying skin, and underlying mucosa mobilized on peripheral neurovascular pedicles containing the fifth and seventh cranial nerves. This flap preserves motor and sensory innervation, and provides excellent functional restoration. The principal limitation of this technique is the increasingly severe microstomia and accompanying abnormal appearance that result with progressively larger lip defects.

When a lateral element is completely missing, a flap designed as a lateral element aesthetic unit is transferred from a nasolabial site or lower lip midline to replace the missing lateral lip elements. Inclusion of the levator anguli oris muscle in a distally based nasolabial flap restores the oral sphincter of the upper lip.

• Reverse Estlander Flap--In 1872 Estlander described a rotation flap from the lateral upper lip around the commissure to repair a defect of the lateral lower lip. The classic Estlander flap will need a secondary revision to restore the sharp angle (commissure) at the corner of the mouth. However, the modified Estlander or reverse Abbe flap preserves the commissure. 

• Webster's Flap adds crescentic perialar excisions to bilateral cheek advancement flaps to yield excellent results in lateral upper lip defects. It is not sufficient for total upper lip reconstruction.

• Levator anguli oris flap (Tobin and O'Daniel, 1990) is an innervated flap that is based at the oral commissure and transposed to replace the lateral lip element.

Lower lip reconstruction

In the lower lip, innervated advancement of the preserved lateral lip elements are preferred to depressor anguli oris flaps unless the defect reaches the commissure on one side.

• Bilateral orbicularis oris flaps (Karapandzic) can be used to reconstruct as much as three fourths of the lower lip. While it provides a complete oral sphincter and oral competence, it often results in a small oral aperture which can be a problem for denture wearers.

• Freeman (1958) or Webster-Coffey-Kelleher (1960) modification of the Bernard bilateral cheek advancement flap technique. Both approaches preserve motor and sensory innervation to the residual lateral lip elements although both distort the oral commissures, and oral circumference is progressively lost as the defect enlarges.

• Gillies's fan flap is basically an extension of the Estlander-type vermillion-bordered flap, enlarged to include tissue lateral to the corner of the mouth. When used unilaterally it is good for defects up to a half of the lower lip. It does not decrease the size of the stoma (mouth opening) much, if at all. The donor defects close directly. The commissure and width of the mouth remain unchanged. However, there is little or no muscular function because it is a denervated flap. This can lead to problems with oral competence and decreased/poor sensation. There may also be some blunting or obliteration of the nasolabial folds.

RECONSTRUCTION of Total Lip
Upper lip reconstruction

• The Abbe-Sabattini flap philtral reconstruction may be performed either concurrently with the lateral element reconstruction or later. Deferring it can be particularly valuable if the reconstruction is asymmetric because the Abbe flap can be placed precisely in the midline after the lip has settled and the lateral element junctional scar ignored.

• Bilateral levator anguli oris flap (Tobin and O'Daniel, 1990) is an innervated flap that is based at the oral commissure and transposed to replace the lateral lip element. In combination with an Abbe flap, it can reconstruct the entire upper lip.

• Bilateral Karapandzic's Inferiorly based Orbicularis Rotation Flap use in combination with an Abbe flap. (picture)

• Bilateral Fan Flap (Gillies') is good for total defects of both the lower or upper lip.

• Kazanjian-Converse technique of superiorly based lower cheek flaps

Lower lip reconstruction

• Bilateral, innervated, depressor anguli oris myocutaneous flaps serve well. These flaps provide a superior functional restoration compared with previously described methods.
• Webster Cheek Advancement Flap can be used for total lower lip reconstruction. It can often result in a tight lower lip and poor lip function.
• Bilateral Fan Flap --see above Gillies's fan flap
• Karapandzic's Technique can be used to reconstruct up to three fourths of the lower lip.

COMPLICATIONS

• Infection is uncommon but is usually heralded by pain on days 4 to 8. They are managed by antibiotics and wound care.

• Hematomas and seromas can occur and will increase the likelihood of flap necrosis.

• Flap cyanosis in the immediate postoperative period is often the result of venous congestion. If thought to be due to excessive wound tension, suspicious stitches can be removed in an attempt to optimize the outcome.

• Flap failure or necrosis is often due to poor planning or design which underscores the need for careful preparation. Cigarette smoking can increase the risk of flap loss by up to three-fold. When necrosis does occur it will usually involve the distal tip and should be managed expectantly. Unless there are signs of local infection, debridement should not be performed as the eschar will serve as a biologic dressing at worst.

Note--most of the photos were scanned in from the SRPS (5th reference below). This is by no means an exhausted review of the flaps possible for lip reconstruction. When the cheek, as well as the lip is missing often free flaps will need to be done to bring into the area new tissue. Often it is the radial forearm flap that is used when that is necessary.

REFERENCES
RECONSTRUCTION OF THE LOWER LIP BY MENTAL V-Y ISLAND NEUROVASCULAR ADVANCEMENT FLAP; Burić Nikola, Krasić Dragan, Vučković Ivica
Lip Reconstruction by Michael R Shohet MD and Maurice M Khosh MD; eMedicine Article; August 19, 2005
Lip Reconstruction; Gordon R Tobin MD and Wayne Stadelmann MD; eMedicine Article, January 30, 2005
V-Y Advancement Flap in Upper-Lip Reconstruction, IDEAS AND INNOVATIONS; Plastic & Reconstructive Surgery. 105(7):2464-2466, June 2000; Narsete, Thomas A. M.D.
Lip, Cheek, and Scalp Reconstruction and Hair Restoration; Selected Readings in Plastic Surgery, Vol 8, No 14; W P Adams Jr MD, S J Beran MD, and F J Tittle MD
Lip Reconstruction; Yamilet Tirado, M.D.; Baylor College of Medicine Grand Rounds, October 6, 2005
Zide B: Deformities of the lips and cheeks. In: McCarthy JG, ed. Plastic Surgery. Vol 3. Philadelphia, Pa: WB Saunders; 1990.
Lip Reconstruction; Plastic and Reconstructive Surgery, Vol 120, No 4, pp57e-64e, September 15, 2007; Anvar, Bardia A. M.D.; Evans, Brandon C. D.; Evans, Gregory R. D. M.D.
Advancement Flaps; Desire Ratner MD and Joseph M Obadiah MD; eMedicine Article, December 4, 2006
Atlas of Head & Neck Surgery--otolaryngology By Byron J. Bailey; Google eBook
Lip Reconstruction; Sarah Weitzul MD and R Stan Taylor MD; eMedicine Article, April 11, 2006
Local Flaps in Head and Neck Reconstruction; Ian T Jackson MD; The C V Mosby Company, 1985.