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23 Lip Shave (Vermilionectomy)
https://t.me/med1917
Fig. 23.16 Appearance 3months after total vermilionectomy
225
Fig. 23.17 Pre-operative supercially invasive squamous cell carcinoma
Fig. 23.18 Appearance 3months after total vermilionectomy
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M. J. Ogledzki and C. A. Ramirez
References
1. de Santana Sarmento DJ, da Costa Miguel MC, Queiroz LM,
Godoy GP, da Silveira EJ. Actinic cheilitis: clinicopathologic
prole and association with degree of dysplasia. Int J Dermatol.
2014;53:466–72.
2. Kaya I, Uslu M, Ozturk A, Apaydin F.Long-term results of vermilionectomy in malignant and premalignant lower lip lesions. JAMA
Facial Plast Surg. 2018;20:253–4.
3. Roldán JC, Teschke M, Feinendegen DL.The vermilionectomy and
the subsequent lower lip reconstruction were introduced by Victor
von Bruns and not by von Langenbeck or von Esmarch as reported
previously. Plast Reconstr Surg Glob Open. 2016;4:e699.
4. Shah AY, Doherty SD, Rosen T. Actinic cheilitis: a treatment
review. Int J Dermatol. 2010;49:1225–34.
5. Robinson JK. Actinic cheilitis. A prospective study comparing four treatment methods. Arch Otolaryngol Head Neck Surg.
1989;115:848–52.
6. Knabel MR, Koranda FC, Olejko TD. Surgical management
of primary carcinomas of the lower lip. J Dermatol Surg Oncol.
1982;8:979–83. https://doi.org/10.1111/j.1524- 4725.1982.
tb01079.x.
7. Marshall DR, Bennett CS. Surgical treatment of lip cancer: the
long term prognosis and functional results. Aust N Z J Surg.
1982;52:525–30.
8. Burket JM. Vermilionectomy for lower lip leukoplakia. Arch
Dermatol. 1967;95:397–9.
9. Dufresne RG, Curlin MU. Actinic cheilitis. A treatment review.
Dermatol Surg. 1997;23:15–21.
10. Field LM.An improved design for vermilionectomy with a mucousmembrane advancement ap. J Dermatol Surg Oncol. 1991;17:833–
4. https://doi.org/10.1111/j.1524- 4725.1991.tb03270.x.
11. Fernandez Vozmediano JM, Romero Cabrera MA, Carrascosa
Cerquero A. Vermilionectomy using the W-plasty technique. J Dermatol Surg Oncol. 1989;15:627–9. https://doi.
org/10.1111/j.1524- 4725.1989.tb03601.x.
12. Lustig J, Librus H, Neder A. Bipedicled myomucosal ap
for reconstruction of the lip after vermillionectomy. Oral
Surg Oral Med Oral Pathol. 1994;77:594–7. https://doi.
org/10.1016/0030- 4220(94)90317- 4.
13. Ay A, Aytekin A. Meshing technique in mucosal advancement aps for vermilionectomy defects. Plast Reconstr Surg.
2003;112:1739–40.
14. Barry RBM, McKenzie J, Berg D, Langtry JAA. Direct primary
closure without undermining in the repair of vermilionectomy
defects of the lower lip. Br J Dermatol. 2012;167:1092–7.
15. Sand M, Altmeyer P, Bechara FG.Mucosal advancement ap versus
primary closure after vermilionectomy of the lower lip. Dermatol
Surg. 2010;36:1987–92.
16. Field LM. Prevention of the "prickling sensation" following surgery for actinic cheilitis. J Am Acad Dermatol. 1988;18:1365–6.
https://doi.org/10.1016/S0190- 9622(88)80120- 8.
17. Pereira CM, Bonan PRF, Pires FR, de Almeida OP.Mucous extravasation phenomenon following vermilionectomy. Dermatol Surg.
2002;28:544.
V andW Lip Excisions
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BrianBisase andAraChalian
24
24.1 Introduction
Because it receives more ultraviolet exposure than the upper
lip, 90% of cases of lip cancer involve the lower lip. The
anatomy of the lips includes three layers: skin, muscle (orbicularis oris), and mucosa. The vermilion (red part) is formed
of non-keratinising mucosa; the “white line” is where the
skin meets the vermilion. Alignment of this zone is the initial
step—and one of the most important steps—in lip skin closure, as minor defects can stand out a lot.
The blood supply includes the superior and inferior labial
arteries, which are branches of the facial artery (Fig.24.1).
They course deep to the mucosal surface of the lip. The
motor nerve supply of the lips is from the facial nerve,
through the buccal and mandibular branches. Innervation for
sensation is from the trigeminal nerve, through the infraorbital branch (upper lip) and the mental branch (lower lip).
Wide excision of cancer in the lower lip frequently requires
full-thickness excision in order to optimise clearance of the
disease and improve survival.
B. Bisase
Department of Oral and Maxillofacial Surgery, Queen Victoria
Hospital National Health Service (NHS) Foundation Trust,
East Grinstead, West Sussex, UK
e-mail: bbisase@doctors.org.uk
A. Chalian (*)
Department of Otorhinolaryngology, Penn Medicine,
Philadelphia, PA, USA
e-mail: chaliana@uphs.upenn.edu
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_24
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Chin muscles
Labial glands
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B. Bisase and A. Chalian
Orbicularis
oris m:
Upper pars
peripheralis
Upper pars
marginalis
Labial artery
Orbicularis
oris m:
Lower pars
marginalis
Lower pars
peripheralis
Chin fat
compartment
Sublingual
mucosa
Mucous
membrane
Transitional
zone
Vermillion
border
Orbicularis
oris m
Attached
gingiva
Skin
Mucolabial
sulcus
Superficial
fascia
Mentalis m
Fig. 24.1 Anatomy of the lips. Left, Paramedial where there may not be much mentalis muscle. Right, In the midline, demonstrating the mentalis
muscle
24.2 Preoperative Checklist,
Considerations, andAnaesthesia
larger defects. Defects encompassing between one-third and
two-thirds of the lip require alternative techniques such as
the staircase technique (progressive horizontal distances that
Ensure that the patient has given appropriate consent after
being informed of all treatment options and of possible complications such as bleeding, infection, wound breakdown,
numbness, scar, vermilion or mucosal irregularity, the need for
involve half of the defect width). Defects greater than 60% of
the lip usually require rotational aps to be closed, using
techniques such as those introduced by Abbe, Estlander,
Bernard, Gillies, McHugh, or Karapandzic.
additional procedures, and recurrence of the primary lesion.
It is also important to ensure that the patient is medically t
for the procedure, including the type of anaesthesia to be used:
• Local anaesthesia (LA)
• Local anaesthesia and intravenous sedation (LA/IV)
• General anaesthesia (GA)
24.4 Surgical Technique
Appropriately position the patient, prepare the site with an
aseptic substance, and mark the margin of the planned excision. Decide on the type of reconstruction and draw this at
or around the excision. Options include V excision with
Antibiotics are not normally required for this procedure.
primary closure, V with pentagonal closure, or a W-shaped
excision with primary closure (Fig.24.2). The W-shaped
excision may be used to avoid crossing the mentolabial
24.3 Indications
crease and to allow for larger defects to be closed
primarily.
V excision with primary closure is considered adequate in
most full-thickness defects encompassing up to one-third of
the lower lip. To avoid crossing the mentolabial groove,
select V resection for smaller defects and W resection for
Administer adequate local anaesthesia (e.g., 2% lignocaine with 1:80,000 adrenaline) with bilateral mental nerve
blocks and local inltration of the incision/excision line.
Using a #15 or #11 scalpel blade, excise the lesion along the
abc
24 V andW Lip Excisions
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Fig. 24.2 Excision and reconstruction of lip lesions (from top left): V excision with primary closure, V with pentagonal closure, W-shaped excision with primary closure
229
def
Fig. 24.3 Closure of V and W lip excisions. (a–c) Three-layer closure of V excision. (d–f) Closure of a W excision. M muscle layer closure; S
skin or supercial layer closure
marked lines and orientate the specimen for pathology.
Obtain meticulous haemostasis using bipolar cautery, or
monopolar if safe to do so. Pay particular attention to the
labial artery.
The vermilion border must be realigned meticulously to
avoid malalignment. It is sometimes advisable to do this rst
and ensure that it is correct. This should be followed by a
careful three-layer closure, including the oral mucosa, the
orbicularis oris muscle, and the overlying skin in individual
layers (Fig.24.3). For oral mucosa closure, we use 4-0 or 5-0
Vicryl Rapide™™ (Ethicon). For muscle to muscle closure,
we use 3-0 Vicryl, and for deep subcutaneous skin, we use
4-0 Vicryl Rapide™. For skin and superior mucosa just
beyond the vermilion, we use 6-0 nylon sutures.
M
S
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B. Bisase and A. Chalian
For surface cutaneous dressings on non-hair-bearing skin,
we employ Steri-strips and brown tape, but we use Vaseline or
a protective spray (such as Opsite) on hair-bearing surfaces.
24.5 Postoperative Care
Patients should be advised to keep the cutaneous aspect dry,
rinse the oral side (with a salt water mouthwash), and minimise tension on the wound for the rst 2–3weeks.
Removal of sutures should be carried out at 7days unless
the patient has had previous radiotherapy or has any other
wound-healing problem, such as long-term steroid therapy.
For these patients, consider removal at 9–10days.
After surface wounds (skin and mucosa) have healed,
bimanual massage of the lip while the deeper wound matures
should minimise deep scar tissue.
Lip Reconstruction withLocal Flaps
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RichardChalmers andOmarA.Ahmed
25.1 Introduction
The lips form the anterior boundary of the oral cavity, and
separate the intraoral contents from the exterior. They are not
only responsible for oral continence but also play an important role in eating, swallowing, and speech.
The lips are mobile, highly specialised structures. From
an aesthetic and functional point of view, it is advisable to
replace lip defects with lip tissue whenever possible.
The lips are composed externally of skin and internally of
mucous membrane. A good knowledge of the anatomical
landmarks of the lips is essential when planning reconstruction (Fig.25.1).
The external landmarks of the upper lip are the philtral
columns, the Cupid’s bow, and the white roll. The philtral
columns are a pair of near-vertical ridges, extending from the
nasal columella to the vermilion border, which are formed by
the underlying orbicularis oris muscles. The philtral columns
merge caudally with the white roll, another ridge formed by
the orbicularis oris muscle. The philtral dimple (philtrum) is
a depression in the central lip between the philtral columns.
The Cupid’s bow is the curved part of the white roll between
the bases of the philtral columns. The main external landmark of the lower lip is the white roll.
A cross-section of the lips reveals the following structures, from external to internal: skin and vermilion, subcutaneous tissue, muscle, submucous glands, and mucosa
(Fig.25.2).
The skin of the lips is hair-bearing, with the hair being
mostly vellus in women and children. It is rich in sebaceous
25
66
Fig. 25.1 Subunits of the lip: (1) Tubercle; (2) Vermilion; (3) Vermilion
border; (4) Cupid’s bow; (5) Philtrum; (6) Philtral columns; (7)
Cutaneous upper lip; (8) Cutaneous lower lip; (9) Labiomental sulcus;
(10) Chin
5
7
5
4
3
2
1
3
8
10
9
1
2
3
R. Chalmers
Department of Plastic and Reconstructive Surgery, University
Hospital of North Durham, Durham, UK
e-mail: rlchalmers@doctors.org.uk
O. A. Ahmed (*)
Department of Plastic Surgery, Royal Victoria Inrmary,
Newcastle upon Tyne, UK
e-mail: omaraa@doctors.org.uk
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_25
Fig. 25.2 Coronal cross-section through lips: (1) Superior labial
artery; (2) Muscle bres; (3) Inferior labial artery; (4) Sensory nerve
supply from the infraorbital nerve and motor supply from the lower
buccal and mandibular branches of the facial nerve; (5) Fat and subcutaneous tissue
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232
Lateral nasal
ior labial
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R. Chalmers and O. A. Ahmed
and sweat glands. Deep to the skin is a signicant amount of
subcutaneous fat, which makes up the bulk of lip thickness.
The vermilion extends from the white roll to the wet-dry border, beyond which it transforms into mucosa. It is important
to understand the distinction between the vermilion and the
mucosa. The vermilion is stratied squamous epithelium
with a thin layer of surface keratin. It contains no glands, and
is dryer and duller in appearance than mucosa. Mucosa is
non-keratinised epithelium that is rich in minor salivary
glands; it lines the inside of the lip.
The lips have a rich vascular supply (Fig.25.3). The arterial
supply is from the superior and inferior labial arteries, which
are branches of the facial artery. Each labial artery communicates with its counterpart across the lip, forming a continuous
arterial circle around the oral sphincter. This allows for considerable versatility inlocal ap design. The arteries lie at the
wet-dry border, just deep to the orbicularis oris muscle, and
send numerous perforators through the orbicularis muscle to
Fig. 25.3 Major blood
supply to the face
the overlying skin. The blood supply to the labial skin is so
rich that local aps can survive even when they do not include
a labial artery. The venous drainage of the lips is more unpredictable than the arterial supply. The labial veins can drain into
the anterior facial veins, the transverse cervical veins, the
supercial temporal veins, and the submental veins.
Knowledge of the lymphatic drainage of the lips is important for oncologic considerations. Drainage from the upper
lip is primarily to the submandibular nodes, but the commissure can drain to the periparotid nodes. Both of these nodal
regions subsequently drain to the jugulodigastric nodes. The
drainage is mostly to ipsilateral nodes, although the midline
of the upper lip can also drain to contralateral nodes. The
lower lip also drains to the ipsilateral submandibular nodes,
except that the midline lip drains into the submental nodes.
Drainage from the central lower lip frequently crosses the
midline. The submental nodes subsequently drain into the
submandibular nodes.
Parietal
branch
Occipital
Posterior
auricular
Orbital
ansverse
fascial
Maxillary
Occipital
Facial
Lingual
Frontal
branch
Supraorbital
Superficial
temporal
Angular
Superior
labial septal
Infer
Submental
25 Lip Reconstruction withLocal Flaps
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25.2 History ofLip Reconstruction
Numerous techniques have been described to reconstruct the
lips. Functional and aesthetic results are best when the lip
tissues, particularly the musculature, are oriented in their
correct anatomical positions.
Lip reconstruction has been practiced since ancient
times. Susruta, the great Indian physician and surgeon,
described lip reconstruction in his compendium of surgery
(Sushruta Samhita) around 600BC [1]. The Roman physician Celsus described the classic wedge excision and primary closure of the lip in the rst century AD.The German
surgeon Dieffenbach described the rst cheek advancement
ap techniques in 1834 [2]. The Italian surgeon Pietro
Sabattini (1838) developed the concept of lip-switch aps
[3], which were popularised in the late nineteenth century
by Abbé [4] and Estlander [5] and are still commonly used.
In 1855, von Burow [6] applied the principle of skin triangle
excisions to facilitate advancement of bilateral cheek
advancement aps for total lip reconstruction. Bernard [7]
described a similar technique in 1852. Modications of the
Bernard and von Burow techniques by Freeman (1958) [8]
and Webster (1960) [9] remain useful to this day. In the
1920s, Gillies introduced the fan ap, aimed at restoring a
competent oral sphincter. McGregor [10] modied the classic Gillies fan ap in 1983. Karapandzic [11] described a
functional neurovascular lip rotation technique for large
defects in 1974. Harii etal. (1975) [12] were the rst to use
microvascular free tissue transfer for extensive defects of
the lip.
25.3 Indications forLip Reconstruction
Most lip defects requiring reconstruction arise from either
tumour resection or traumatic loss. Non-melanoma skin cancers make up the majority of tumours. Of these, basal cell
carcinomas (BCCs) tend to occur in the upper lip and squamous cell carcinomas (SCCs) in the more sun-exposed lower
lip. Both BCCs and SCCs are more common in the elderly.
Malignant melanomas can also occur on the lips, including
in young people. Traumatic lip defects usually occur in
young, healthy patients.
25.4 Principles ofLip Reconstruction
To maintain oral continence, an attempt should always be
made to preserve the nerve supply to the reconstructed lip.
Muscle-carrying lip vermilion should also be preserved
where possible. Whenever possible, the lip muscles should
be anatomically oriented.
Residual lip tissue is best to reconstruct the lip. Adjacent
tissues should be used when a lip defect is too large to be reconstructed with the remaining lip tissue. Distant tissues should be
used for reconstruction only when local tissue is insufcient to
reconstruct the defect. It is important for the reconstruction to
allow sufcient oral opening for feeding and dental care.
25.5 Reconstruction oftheUpper Lip
Supercial defects of the upper lip can often be reconstructed
by simple methods. Central defects involving less than half
of the distance between the philtral columns can be repaired
either primarily or with a wedge resection. In all wedge
resections, the orbicularis muscle must be accurately repaired
for normal lip movement. If the defect involves more than
half of the central lip (without crossing the philtrum), a fullthickness skin graft (hair-bearing in men) can give adequate
results. For lateral defects that are less than half the width of
the lateral lip, wedge resection is effective, but a local ap
from the cheek may be a good option if the defect is larger.
Alternatively, a full-thickness graft can be just as
acceptable.
The management of full-thickness defects of the upper lip
depends on their size and location. Defects up to one-third in
width can usually be closed directly, often with the aid of
perialar crescentic excisions [13]. Primary closure of central
defects can result in a narrow central lip, but this is often
cosmetically acceptable.
When a central defect is greater than half of the upper lip,
an Abbé-Sabattini ap (Fig.25.4) from the lower lip is indicated. In such situations, the whole central lip subunit (from
philtral column to philtral column) should be excised and the
width and height of the ap should be equal to that of the
upper lip defect. The Abbe-Sabattini ap is based on a single
inferior labial artery and should ideally be harvested from
the central lower lip. It should include the central raphe of
the orbicularis oris muscles. When raising the ap, the lower
lip is completely divided on the non-pedicle side, making a
note of the location of the labial artery. On the pedicle side,
the artery and a small cuff of mucosa are preserved. The
donor defect on the lower lip is closed primarily before the
ap is inset in layers to the upper lip and lower nasal columella. The pedicle can be safely divided at 2–3weeks. In
addition to resectional defects of the lip, this ap is ideal for
secondary correction of bilateral cleft lips when there is
inadequate upper lip height and volume. A major disadvantage is the two stages required for transfer.
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R. Chalmers and O. A. Ahmed
2
1
Fig. 25.4 Abbe-Sabattini ap: (1) Design of ap and subunit excision; (2) Rotate the ap into the defect on its pedicle; (3) Close the donor site
1
2
Fig. 25.5 Estlander ap for partial commissure reconstruction: (1) Lesion marked out; (2) Corresponding ap marked to allow the medial lower
lip pedicle to become the new commissure; (3) Rotate the ap into the defect; (4) Inset and closure of donor site
The Abbe-Sabattini ap can also be used to replace lateral
25.6 Reconstruction oftheLower Lip
3
3
4
lip defects larger than a third if the defect does not involve
the oral commissure. If the lip switch ap is combined with
perialar crescentic skin excision and lip advancement, this
narrows the lateral upper lip defect so that a smaller ap is
required from the lower lip.
For defects of the upper lip greater than 50%, a larger lip
switch ap can be used in combination with bilateral perialar
crescentic excision and advancement. Bilateral medial
advancement aps can then close the large lower lip donor
Supercial defects of the lower lip are often best treated by
full-thickness wedge excision and primary closure. More
extensive supercial defects may be simply reconstructed by
a full-thickness skin graft, especially if the bulk of the lip
muscle is still present.
Techniques to reconstruct full-thickness defects of the
lower lip can be conveniently classied into three groups,
depending upon the size of the lip defect:
defect.
Defects close to the commissure can be reconstructed in a
single stage by the Estlander ap (Fig.25.5). This technique
is similar to the Abbe-Sabattini ap but reconstructs the oral
• Defects of up to one-third of the lip width
• Defects of between one-third and one-half of the lip width
• Defects greater than one-half of the lip width
commissure, though the new commissure is blunted. When
performing lip-sharing procedures, it is important to maintain a balance between upper and lower lip length.
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