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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_688_Библиотеки_им_академика_М_И_Перельмана
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11 Lips/Chin
Abbe Flap
Indications: Medium-sized defects, away from the commissure, two-stage ap.
Technique: The defect is modied to have parallel wound edges. The ap is
marked to have a similar height of the donor defect, but the width can be reduced
by up to 30%, to make use of the redundancy of the remaining lip. A full-thickness
incision is made along one of the borders of the ap (skin, muscle, mucosa), but
the incision along the other border is stopped short of the vermillion, to avoid
damage to the vascular pedicle (labial artery). The ap is rotated into the defect,
and the wounds are closed in three layers, taking care to protect the labial artery.
The donor site is closed primarily. The pedicle is divided in 3–4weeks, and any
revision to accurately approximate the vermillion border carried out at this stage
(Figs.11.26a–d, e–l).
Tips: Patient compliance is vital, and the patient should be counselled appropri-
ately, prior to the procedure. The initial incision on the side of the ap with the
vascular pedicle should stop short of the vermillion border. With extreme care, further dissection can be carried out through the skin and part of the muscle, to help
accurately approximate the vermillion border during the primary reconstruction. As
discussed at the beginning of the chapter, the labial artery runs along the free border
of the lip, below the mucosa on the posterior aspect of the orbicularis oris and maintaining a portion of the muscle above the vessels offers some additional protection.
ef
Full-Thickness Defects
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a b
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c
Fig. 11.26 Abbe ap. (a) Markings for excision and ap, (b) Excision defect and ap raised, (c)
First stage ap inset and suturing, (d) Second stage after ap division, (e) Defect upper lip, (f) Flap
raised lower lip, (g) Initial closure distal ap edge, (h) subsequent closure proximal ap edge, (i)
Closure donar site - nal appearance rst stage, (j) Final appearance - rst stage lateral view, (k)
Apperanace after second stage ap division, (l) Post operative appearance
d
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ij
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11 Lips/Chin
Fig. 11.26 (continued)
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Abbe–Estlander Flap
Indications: Medium-sized defects involving the commissure.
Technique: The ap is marked to have a similar height of the donor defect, but
the width can be reduced by up to 30%, to make use of the redundancy of the
remaining lip. A full-thickness incision is made along the lateral border of the ap
(skin, muscle, mucosa), but the incision along the media border is stopped short of
the vermillion, to avoid damage to the vascular pedicle (labial artery). The ap is
rotated into the defect, and the wounds are closed in three layers, taking care to
protect the labial artery (Fig.11.27a–d). The donor site defect is closed primarily.
The intact medial border now forms the new commissure.
Tips: The initial incision on the side of the ap with the vascular pedicle should
stop short of the vermillion border. With extreme care, further dissection can be carried out through the skin and part of the muscle, to help accurately approximate the
vermillion border during the primary reconstruction. As discussed at the beginning
of the chapter, the labial artery runs along the free border of the lip, below the
mucosa on the posterior aspect of the orbicularis oris and maintaining a portion of
the muscle above the vessels offers some additional protection. The residual asymmetry of the commissure improves with time and might need revision at a later date.
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11 Lips/Chin
Fig. 11.27 Abbe-Estlander ap. (a) Markings for excision and ap, (b) Excision defect and ap
raised, (c) Flap mobilised into defect, (d) Final closure
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Unilateral/Bilateral Perialar Crescentic Advancement Flap
Indications: Medium-sized defects.
Technique: The defect is modied to obtain parallel lateral edges and extended
superiorly, to place the suture line along the base of nose, alar facial sulcus. An incision is made from the base of the defect, along the base of the nose and extended
laterally around the alar facial sulcus. The dissection is through skin, subcutaneous
tissue and muscle, but the mucosa along the depth of the labial sulcus is initially
preserved. The aps are mobilised medially and the mucosa at the base released at
this stage as required. Burrows triangles are excised along the alar facial sulcus. The
wound is closed in three layers, taking care to accurately approximate the vermillion border (Fig.11.28a–d).
Tips: The difference is length of the wound margins can be accommodated by
differential suturing. Any dog ears that develop are excised along the alar facial
sulcus. Accurate approximation of the vermillion is mandatory. In unilateral aps,
the medial suture line can be placed along the philtral ridge or perioral rhytids.
Mucosal incisions can often be smaller than the corresponding skin component.
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a b
11 Lips/Chin
Fig. 11.28 Perialar cresentric advancement ap. (a) Markings for excision and ap, (b) Excision
defect and ap incisions, (c) Flaps raised, (d) Final closure
Full-Thickness Defects
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Nasolabial Flap+Abbe Flap
Indications: Total upper lip defect.
Technique: An Abbe ap is raised to reconstruct the philtrum (see Fig.11.26).
Two inferiorly based nasolabial ap are raised, with the inferior extent of the medial
incision stopping at the level of the planned commissure. A trail transfer will help
determine the size of the ap, and the tip is triangulated to facilitate primary closure
of the secondary defect. The dissection is deepened up to the periosteum superiorly
and mucosa inferiorly. The aps are mobilised, and the mucosa at the depth of the
vestibule is released laterally to reconstruct the inner layer. The nasolabial aps are
sutured to the Abbe ap in layers (Fig.11.29a–e). The Abbe ap is divided in
3–4weeks, and any additional revision of the vermillion undertaken at this stage
(Fig.11.29f).
Tips: The nasolabial aps imports “new” cheek tissue into the defect, and the
reduction in size of the oral aperture is minimised. The motor and sensory nerve
supply is divided (unlike a karapandzic ap) though partial ingrowth occurs over a
period of time. The reconstruction of the lateral vermillion is however often less
than ideal.
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11 Lips/Chin
a
c
b
d
e
Fig. 11.29 Nasolabial ap + Abbe ap. (a) Markings for excision and aps, (b) Excision defect
and aps raised, (c) Initial inset of Abbe ap, (d) Subsequent closure of lower lip donar site, (e)
Final closure - rst stage, (f) Second stage division of pedicle and closure
f
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Chin Defects
The chin unit is dened by the mentolabial fold superiorly and laterally and the
lower border of the mandible inferiorly. The RSTLs are arranged in a curvilinear
pattern, and scars are ideally designed to lie parallel to these (See Figs.11.1, 11.2).
Primary Closure
Indications: Small defects.
Technique: The defect is modied to an ellipse, to orient the eventual scar along
the RSTLs. The wound margins are undermined, and the defect is closed in layers
(Fig.11.30a–c).
Tips: Care should be taken to avoid distortion of the mentolabial fold/lower lip,
associated with the lengthening of the scar following elliptical excision.
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