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64
e
Depr
inferioris muscle
S. Kohlert
Musculature
There are multiple muscles involved in the movement of the upper lip including the
levator labii superioris, the levator labii superioris alaeque nasi, levator anguli oris,
and the zygomaticus major and minor muscles (Fig.5.3). These muscles converge
at the modiolus (a bromuscular structure at the corner of the mouth). Muscles that
retract the lower lip include the depressor labii inferioris, the depressor anguli oris,
the platysma, the risorius, and the mentalis. Sphincteric action is achieved by the
orbicularis oris muscle [9] (Table5.1).
Innervation
Motor innervation for all of the above muscles is provided by branches of the
facial nerve.
Sensory innervation of the upper lip is primarily from the labial branch of the
infraorbital nerve (from CN V2), while the mental nerve (from the inferior alveolar
branch of V3) is responsible for lower lip sensation.
Infraorbital
nerve
Superior
labial artery
Orbicularis oris
muscle
Inferior labial
artery
essor anguli
oris muscle
Depressor labii
Fig. 5.3 Relevant muscular and neurovascular anatomy
Zygomaticus
minor muscle
Zygomaticus
major muscle
Facial artery
Risorius muscl
5 Reconstruction oftheLip
Table 5.1 Relevant muscular anatomy of the lip
Muscle
Orbicularis oris Upper lip: alveolar border
Levator labii
superioris
Levator labii
superioris
alaeque nasi
Levator anguli
oris
Zygomaticus
major
Zygomaticus
minor
Depressor labii
inferioris
Depressor anguli
oris
Platysma Skin/subcutaneous tissue
Risorius muscle Parotid fascia Skin at angle of
Mentalis Incisor fossa (mandible) Skin of the chin Elevates and protrudes
Origin Insertion
Modiolus Sphincteric action, lip
of maxilla
Lower lip: mandible
(lateral to mentalis)
Orbit Modiolus Elevates the upper lip
Frontal process of maxilla Nasal component:
alar cartilage and
nasal skin
Lip component:
modiolus
Canine fossa (maxilla) Modiolus Elevates the upper lip at
Zygoma, anterior to
zygomaticotemporal suture
Zygoma, posterior to
zygomaticomaxillary
suture
Oblique line of the
mandible
Oblique line of the
mandible
of neck
Modiolus Elevation and posterior
Modiolus Elevates upper lip
Modiolus
Multiple areas
including
modiolus
mouth
Action
protrusion
Elevates the upper lip
and dilates the nostril
the angle of the mouth,
deepens nasolabial fold
retraction of upper lip
Depresses lower lip
(among other non-liprelated actions)
Stretches lower lip,
depresses lower lip,
pulls lower lip laterally
the lower lip
65
Arterial Supply
The upper lip is supplied by the superior labial branch of the facial artery, as well as
the superior labial branch of the infraorbital artery. The lower lip is supplied by the
inferior labial artery (also a branch of the facial artery).
Basic Considerations andReconstructive Approach
Form andFunction
Restoration of normal form and function is the fundamental goal of the reconstructive surgeon. Impairment of either (or both) can have signicant psychosocial implications for the patient. Primary functions of the lips include facial expression,
66
S. Kohlert
speech and articulation, oral competence, and swallowing. Impairment of motor
function can prevent a patient from smiling, kissing, or sucking through a straw
[10]. Major lip reconstruction can impair a patient’s ability to articulate certain
sounds, and poor oral competence can lead to drooling. Adequate lip closure is also
an important part of the swallowing mechanism, permitting pressure formation
within the oropharynx that facilitates bolus propagation [11]. Furthermore, patients
with poor lip function and/or microstomia may no longer be able to wear dentures
as a result, limiting their ability to enjoy many solid foods.
Achieving a satisfactory cosmetic outcome should also be of absolute importance for the surgeon. Patients with central postoperative facial defects are perceived more negatively by others, even more so than those with peripheral facial
defects [12]. It is therefore understandable that patients undergoing facial skin cancer surgery report being self-conscious and avoid socialization after surgery [13].
Lip cancer patients were found to be among a subgroup of oral cancer patients who
reported poorer psychosocial adjustment scores in post-treatment surveys [14].
Lip reconstruction can be highly challenging, especially for larger defects.
Extremely careful analysis of the defect including the size, depth, involved anatomical subunits, and quality and availability of the surrounding tissue (especially in
patients with prior surgery or disease) is paramount in obtaining satisfactory cosmetic and functional results. Furthermore, full thickness defects require a meticulous multilayer closure. A proper reapproximation of the muscle layer is critical for
the restoration of lip function and oral competence. When closing the external layer,
it is also critical to properly align the vermillion border in order to prevent highly
visible step deformities. We recommend that the rst suture placed typically be a
single tacking suture to precisely reapproximate vermillion border. While suture
selection varies from surgeon to surgeon, we typically will use 5-0 chromic gut
sutures for mucosal closure, vicryl sutures for the reapproximation of the muscular
layer and deep dermis, and 6-0 Prolene for supercial closure of the skin.
Reconstructive Ladder Approach
The reconstructive ladder is a well-known, incremental approach to the defect
reconstruction (Fig.5.4). It can be helpful to use this model as a framework for
determining the best reconstructive option for the patient. As a general rule of
thumb, the reconstructive surgeon should aim to use the least complex (i.e., lowest
on the ladder) option that can reasonably be expected to provide the return of satisfactory form and function. For example, while certain small lip defects can be
closed primarily or even left to heal by secondary intention, more advanced defects
will require free ap reconstruction. A multitude of options for reconstruction spanning the length of the reconstructive ladder will be discussed in this chapter.
Complex
Simple
5 Reconstruction oftheLip
• Tissue transplantatio
• Free tissue transfer
• Regional flap
• Local flap
• Tissue expansion
• Bioengineered tissue
• Skin graft
• Primary intention
• Healing by secondary intention
67
Fig. 5.4 The reconstructive ladder
Perioperative Care
Intraoperative Setup
When feasible, we elect for nasotracheal intubation for patients undergoing surgical
lip reconstruction in order to facilitate exposure and prevent distortion of the soft
tissue related to the tube. The oral cavity and oropharynx are is cleansed with 0.12%
chlorhexidine and the face prepped with Betadine paint. A single dose of IV cephalexin is administered within 30min prior to the incision (for patients with an anaphylactic penicillin allergy, clindamycin is a suitable alternative).
68
S. Kohlert
Postoperative Care
Antibiotic ointment (e.g., bacitracin ointment) is applied to the surgical site three
times daily for the rst week and is subsequently transitioned to a petroleum-based
ointment such as Aquaphor® or Vaseline®. The area is gently cleansed with saline
prior to each application. No systemic antibiotics are prescribed postoperatively in
most cases. Antiplatelet and anticoagulant medications are typically held for 3days
postoperatively unless the patient’s prescribing physician feels strongly that they be
resumed immediately postoperatively. Ice packs are avoided to prevent vasoconstriction. Nonabsorbable sutures are typically removed 5 to 7days postoperatively.
Partial Thickness Reconstruction
Partial Thickness Defects: Vermillion
See Table5.2.
Secondary Intention
Healing by secondary intention has been shown to be an appropriate option for
small-to-moderate defects (up to 2.5cm) of the vermillion or mucosal lip. Healing
by secondary intention should be avoided in patients with more than 2mm of cutaneous lip involvement or extension into the underlying muscle so as to avoid cosmetic and functional impairments including wound contracture with scar depression
and oral incompetence. Proper wound care is essential for obtaining satisfactory
cosmetic and functional results. Reepithelialization typically occurs within 3 to
5weeks. Caution should be taken in employing this approach in poorly compliant
patients or for those on antiplatelet/anticoagulant therapy [15].
Some authors also advocate for the use of acellular dermal matrix (e.g.,
AlloDerm®, Cytal Wound Matrix) to assist as a scaffold for healing by secondary
intention and have demonstrated satisfactory cosmetic and functional results even
with large defects involving much of the length of the vermillion lip [16].
Vermillion Advancement Flap
Even very large defects limited to the vermillion can be repaired with vermillion
advancement aps. Wide undermining of the surrounding labial mucosa is performed in a plane just supercial to the orbicularis oris. The mucosa is then advanced
and secured to the remaining vermillion or cutaneous lip. Potential drawbacks of
this procedure include persistent hypoesthesia, apparent loss of lower lip fullness,
and distortion of the vermillion border.
Table 5.2 Reconstructive
options for partial thickness
defects (vermillion only)
– Healing by secondary intention
– Primary closure
– Vermillion advancement ap
– FAMM ap
5 Reconstruction oftheLip
69
FAMM Flap [17]
The facial artery musculomucosal (FAMM) ap is an axial ap based on the facial
artery. It is harvested from the cheek and has multiple uses in oral cavity and oropharyngeal reconstruction. Pribaz and colleagues described its use to restore a normal appearing vermillion for patients with large defects [17].
Partial Thickness Defects: Cutaneous
See Table5.3.
Primary Closure
Small cutaneous defects can be closed by primary closure alone. Primary closure
should not be attempted for large defects as this can lead to poor scarring and distortion of the normal anatomy.
Skin Grafting
Skin grafts often have poor color and texture matching with the lip and come with
the risk of pincushioning [18]. While skin grafting is not commonly performed in
the reconstruction of cutaneous lip defects, it can play a role in carefully selected
patients. Luce recommends that full thickness skin grafts (FTSGs) only be used for
small defects of the superior lip at the nasal sill [8], while others have reported satisfactory results after using the same for the defects of the philtrum as well [16].
FTSGs have been used for the repair of major upper lip defects in burn victims [19,
20], and split thickness skin grafts are used to cover functional gracilis muscle aps
for large full thickness lip defects (as discussed later in this chapter). Given the
mobile nature of the lips, a bolster dressing is of utmost importance if a skin graft is
to be used in order to prevent graft shear.
Local Flaps
A wide array of local aps can be employed including the ergotrid ap, V-Y
advancement ap, alar-crescent ap, nasolabial ap, and the Karapandzic ap. Each
of these aps are discussed below (see the Full Thickness Reconstruction section
for a discussion on the alar-crescent and Karapandzic aps).
Table 5.3 Reconstructive
options for partial thickness
defects (skin only)
– Primary closure
– Skin graft
– Ergotrid ap
– V-Y advancement ap
– Alar crescent ap
– Nasolabial ap
– Free tissue transfer
70
S. Kohlert
Ergotrid Flap
The term “ergotrid” is used to describe the cutaneous upper lip (i.e., the skin between
the base of the nose and the vermillion border of the upper lip, marked laterally by
the nasolabial fold on either side). Described in 2011, the ergotrid ap is a rotationadvancement ap based on branches of the superior labial artery [18]. This ap is
well suited for small-to-moderate sized skin defects on the upper lip. It is especially
useful in older patients with an increased laxity of the surrounding skin and deep
nasolabial folds for scar camouage.
The incision is designed to start at the lateral aspect of the defect and extend into
the nasolabial fold. The surrounding skin is then widely undermined supercial to
the orbicularis oris muscle. The ap is then advanced, and a standing cone is typically excised superomedially. The ap is then inset in the usual fashion (Fig.5.5).
In the event that the ergotrid ap cannot be rotated sufciently to ll the defect,
it can be converted into a V-Y advancement ap (based on perforators from the
facial artery) by extending a separate incision inferiorly.
Fig. 5.5 The Ergotrid ap
5 Reconstruction oftheLip
71
cba
Fig. 5.6 Melolabial ap for upper lip reconstruction
Melolabial Flap
A melolabial ap (Fig.5.6) can be used for cutaneous defects of both the upper and
lower lips. Both superior and inferiorly based melolabial aps can be used for lip
reconstruction. A full description of this ap is provided in an earlier chapter of
this book.
Full Thickness Reconstruction
As previously discussed, the unique anatomical considerations of the upper lip render upper lip reconstruction more complex than lower lip reconstruction. Given the
special considerations required for these cases, upper and lower lip reconstructions
will be discussed separately.
Special Considerations: Lower Lip
Lower lip defects are more common than upper lip defects due to the higher incidence of malignancy on the lower lip [21]. Fortunately, as previously discussed, the
anatomy of the lower lip is less complex than the upper lip, and defects are thus
typically easier to reconstruct. Available reconstructive options differ based on the
length of the defect (Table5.4).
Small Defects
Primary closure can be achieved in defects measuring up to 40% to 50% of the lip
length, especially in elderly patients with increased lip laxity [22, 23]. Surgical
techniques include wedge resection (Fig.5.7) and W-plasty (Fig.5.8).
Larger Defects
Larger defects require more complex reconstruction. Defects measuring less than
two-thirds of the lip can typically be corrected in a satisfactory manner with local
tissue rearrangement. Options for correction of medium-to-large-sized central lip
defects include bilateral lip advancement aps, stair-step advancement aps, and
cross-lip aps such as the Abbe ap. For defects involving the oral commissure, the
72
3
3
2
3
2
Table 5.4 Reconstructive options for full thickness lower lip defects
S. Kohlert
Defect <
– Wedge (V or W) with
Fig. 5.7 Wedge resection with primary closure
1
of lower lip
primary closure
1
Defect
Commissure not involved – Combination (synergistic use) of
– Abbe – Gillies fan ap
– Bilateral lip
Commissure involved – Bernard–von Burow
– Estlander – Webster
– Karapandzic – Regional aps
–
of lower lip
advancement
Defect >
– Extended Karapandzic
– Free aps
of lower lip
3
local aps, see table below
ba
Estlander ap (another cross-lip ap) and the Karapandzic ap are commonly
employed.
Very large defects (including subtotal and total defects) can be approached with
complex local aps such as the Gillies fan ap, the extended Karapandzic ap, the
Bernard–von Burow ap, as well as its subsequent Webster modication. Surgeons
can also be creative in combining the use of multiple different local aps in order to
obtain a satisfactory reconstruction of these major defects (Table5.5).
Regional tissue transfer has been reported for major lip reconstruction. Potential
donor sites include the radial forearm, ALT, gracilis, and more. Osteocutaneous
aps including the bula, scapula, and osteocutaneous forearm have also been used
for complex defects which also involve the mandible.
Special Considerations: Upper Lip
As previously discussed, the upper lip can be broken down into multiple anatomical
subunits, and an accurate reconstruction of the upper lip is more challenging as a
result. One of the most challenging areas in the upper lip to reconstruct is the
5 Reconstruction oftheLip
73
Fig. 5.8 W-plasty
a
b
Table 5.5 Published
examples of synergistic local
aps for the reconstruction of
large/complex defects
– Karapandzic + bilateral cross-lip aps [24]
– Abbe + bilateral stair-step aps [25]
– Double rhomboid with Estlander [23]
– Combined Karapandzic + Webster [26]
– Lip switch + composite modiolus [27]
– Bilateral nasolabial + pedicled submental
ap [28]
– Bernard–von Burow + Abbe [29]
philtrum, along with the lateral philtral columns. A careful consideration to the specic reconstruction of the philtral conguration is fundamental for defects involving
the central upper lip, as the loss of denition in this area tends to result in an eyecatching cosmetic deformity. Similar to the basic principles of other subsites of