Reconstruction of the Lip -- Part I

Updated 3/2017 -- photos and all links removed as many no longer active and it was easier than checking each one. 

There are many reasons that the lip may need surgical repair or reconstruction.

• Neoplastic disorders make up the majority of lip pathology encountered by surgeons. Squamous cell carcinoma (SCC) is the most common malignancy affecting the lip with 90% occurring on the lower lip. Basal cell carcinoma is the most common tumor of the upper lip.

• Trauma -- includes animal bites, automobile accidents, interpersonal violence, and electrical burns. Picture is of a dog bite to the lower lip, before and after repair.

• Congenital disorders -- include cleft lip, hemangiomas, and congenital nevi

The first mention of a labial repair was made in India back in 1000 b.c.. Most modern techniques were developed during the nineteenth century and have continually evolved since that time. Tagliacozzi originally popularized tissue transfer techniques in the late 16th century. Von Burrow first used the technique of skin triangle excisions to facilitate flap advancement in the early 19th century. In 1834, Dieffenbach described the first cheek advancement flap techniques. The late 19th century was a time of the popular contributions of Abbe, Sabattini, and Estlander whose names remain attached to flaps they described and continue to be used today. Karapandzic introduced the myoneurovascular pedicled advancement flap, and Hari and Ohmori performed the microvascular free tissue transfer for lip reconstructions in 1974.

The essential components of lip reconstruction are:

• Complete skin cover and oral lining
• Semblance of a vermillion
• Adequate stomal diameter (large enough mouth opening)
• Sensation
• A competent oral sphincter (controls drool and food loss)

Before proceeding with a lip reconstruction, there are many factors that need to be considered.

• The age of the patient -- An elderly patient, for example, has more loose soft tissue from the relaxed skin tension lines as a result of dynamic facial movements that result in a better ability for advancement, rotation and transposition of the tissues.
• Sex of the patient-- In males , there is the need to consider hair bearing skin prior to advancement or rotation of flaps. On the other hand, women have the ability to apply cosmetics for camouflage, such as lip liner and permanent tattooing.
• Previous operations that may have compromised the labial vessels may be a contraindication to the use of a pedicled labial flap.
• The hexagonal lip esthetic subunit must be consider. In general, entire subunits must be excised and reconstructed to conform to the esthetic principles of scar camouflage.

1. The cosmetic subunits of the upper lip include two lateral segments and one central or philtral unit.
2. The lower lip is a single unit. Still, it is helpful to consider whether the defect is more central or lateral.
3. Another cosmetic subunit to consider is the vermillion. Defects involving only the vermillion should be reconstructed within that cosmetic subunit whenever possible.

• Local tissue should be used whenever possible. This helps to provide both minimal donor-site morbidity and the best overall color and texture match.
• Vermillion and skin must be excised to allow tension-free closure.
• The oral sphincter is reconstructed whenever possible by transposition of the donor muscle into alignment with the sphincteric muscle.
• Categorization into partial or full-thickness defects also identifies ideal reconstructive methods. Defects that involve a full-thickness portion of the lip (i.e., skin, muscle, and mucosa) require full-thickness repair.
• Small full-thickness defects, between a fourth and a third of the lip, may be closed primarily. A major exception is a defect ablating the philtrum, which destroys a significant aesthetic anatomic feature. Such defects are best reconstructed with an Abbe flap from the lower lip midline.
• The junction between the vermilion and surrounding skin is outlined by a linear prominence, the white roll. The excision of the white lip will allow symmetry in primary closure. Excision of tissue is usually in the shape of a V; however, a pentagonal or W technique for resection can be performed. (check out the above photo of the dog bite patient)
• Surgical incisions must cross the skin-vermillion junction at 90-degree angles. This junction must be re-aligned properly during the closure as even a 1-mm discrepancy in the outline of the white roll is noticeable at a distance of 3 feet (Zide).

Partial Thickness Defects of the Vermillion

Small superficial defects limited to the vermillion may be allowed to heal by secondary intention with good results. However, larger or deeper defects or wounds near the vermillion border risk distortion if allowed to heal in this manner. Full-thickness grafts from the labial or buccal mucosa may be used, but often develop trapdoor deformity or mismatch color, texture, and thickness with the surrounding vermillion.

Defects that are less than 40% of the vermillion width may be repaired using a bilateral vermillion rotation flap. This flap utilizes adjacent vermillion to rotate centrally. The arcs of the rotation flap are drawn along the vermillion border with the redundant triangle of skin (dog ear) removed posteriorly.

Advantages include:

• Maintains the anterior-posterior dimension of the lip
• Avoids redirection of beard hairs,
• Decreased risk of persistent hypoesthesia compared to mucosal advancement flap repair.

For defects approaching 50% of the vermillion width or greater, a complete vermillionectomy and mucosal advancement flap repair may be necessary.

Advantages include:

• Useful for large defects of the vermillion subunit.
• The removal of the entire vermillion reduces the risk of subsequent malignancy from adjacent actinic cheilitis.
• The "cosmetic unit" is maintained by treating the entire vermillion unit.

Disadvantages include:

• May decrease the anterior-posterior dimension of the lip
• May give a more rounded and reddish color to the reconstructed vermillion
• Patients may have persistent hypoesthesia (decreased sensation)

Cutaneous Lip Defects

Often small cutaneous (skin only, not vermillion, not muscle)defects of the lateral cutaneous lip can be closed in a simple, linear fashion along the relaxed skin tension lines (think of the lines formed when using a straw). It is better for the closure to cross (at 90 degree angle) the vermillion border than to stop short and create a protrusion of tissue.

For larger defects,

Advancement flaps are the very useful for repair for partial-thickness defects of the lateral cutaneous lip. These flaps works well for the upper and lower lip due to the abundant reservoir of cheek and jowl tissue. Advancement flaps are created by incisions which allow for a “sliding”movement of the incised tissue. The movement is in one direction and the flap "advances" directly over the primary defect. The basic design of an advancement flap is to extend an incision along parallel sides of the defect and then directly advance the tissue over the defect. Complete undermining of the advancement flap as well as the skin and soft tissue around the flap pedicle is very important.

The classically designed advancement flap has a flap length to width ratio of around 1:2 and advances tissue a distance approximating the width of the flap. Advancement beyond this is possible, but the tension of the flap may increase dramatically, and the distal blood flow may become compromised and lead to distal flap necrosis. The following are different types of advancement flaps:

• Monopedicle is a single pedicle advancement flap is the most basic of the advancement flaps. The typical ratio of defect length to flap length is 3:1. It is made by wide undermining prior to parallel incisions preferably in skin crease lines. The flap is inset with key stitches prior to removal of standing cones.
• Bipedicle advancement flap is typically made when a single-pedicle advancement flap does not allow sufficient tissue for closure of the defect. The basic principles and technique are the same as those for the monopedicle advancement flap. A disadvantage of this flap may be the potentially long suture line.
• V-Y flap is a unique flap where a V shaped flap is moved into a defect with primary closure of the donor area leaving a final Y shaped suture line. It is pedicled from the underlying subcutaneous tissue rather than the surrounding skin.
• A-T flap represents a type of bilateral advancement flap where a triangular defect is closed by advancing tissue from either side of the defect. The advantage is that the defect can be divided in half by the use of the two flaps allowing placement of the incisions in natural creases, junctions of aesthetic units, or in the hairline. It works very well along the lip with the horizontal limb at the vermillion.
• Cheek advancement flaps are optimally used in the cheek where the increased elasticity and mobility of the skin here allows for wide undermining and closure of medium to large defects along the medial cheek. This flap is not a pure advancement, but also relies on rotation.

The basic rotation flap is a simple pivotal flap. It is curvilinear in shape and rotates around a pivotal point near the defect. It is designed immediately adjacent to the defect and only one side of the defect is the advancing edge of the flap. As with all pivotal flaps, a dog-ear will develop at the base of the flap. A Burow’s triangle can be removed to facilitate repair to the donor site wound. If done at the base of the flap, it will shift the position of the pivotal point and thus change the wound-closure tension vector as well as the location of the standing cutaneous deformity.

There are many advantages to the rotation flap. The flap has only two sides, thus it does lend itself very well to having both edges placed in borders of aesthetic units of the face or into one aesthetic border and one RSTL. The flap is broad based and therefore its vascularity tends to be reliable.

The island pedicle flap can also be useful for defects of the lower lip and the upper lip. This flap carries it's blood supply with it, but the vessels will also limit how far it can move. Care must be taken to adequately undermine and dissect this flap to assure minimal tension on the mobile vermillion border.

Transposition flaps are harvested at one site and transferred to a site immediately adjacent to the base of the flap. They differ from rotation flaps in that their final axis is linear, whereas the rotation flap has a curvilinear axis. This difference enables the final closure to have less wound tension and a scar in a more favorable axis. The most important element of design of a transposition flap is the location of the pivot point. These flaps include:

• Rhomboid or Limberg flap is based on four equal sides with corresponding 60 and 120 degree angles. After careful design there are four potential donor flaps from which to choose in order to appropriately align the final scar in an inconspicuous area and prevent surrounding tissue distortion.
• Dufourmental flap is slightly more complicated with angles varying from 60 to 90 degrees but there still exists the choice of four potential donor flaps.
• Bilobed flaps are double transposition flaps that share a single base. They move around a pivotal point and invariably develop a standing cone (dog-ear) that is dependent upon the arc of rotation. The primary flap is to repair the surgical defect and the secondary flap is used to repair the flap donor site. The secondary flap defect is then closed primarily. The primary use is in closing defects of the lower third of the nose. A disadvantage of the flap is that the resulting scar is unable to follow skin tension lines in many cases.

COMPLICATIONS
Fortunately, complications are not common with local flaps in the face which accounts for their popularity.

• 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.

REFERENCES
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 & 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.
Lip Reconstruction; Gordon R Tobin MD and Wayne Stadelmann MD; eMedicine Article, January 30, 2005
Novel Flaps for Lip Reconstruction; Advances in Derm Surg, Vol 11, No 6; Daufman A J, Rohrer T E
Advancement Flaps; Desire Ratner MD and Joseph M Obadiah MD; eMedicine Article, December 4, 2006