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Table 5.6 Reconstructive options for full thickness upper lip defects
S. Kohlert
Defect <
Philtrum
– Alar crescent ap – Abbe ap – Abbe + nasolabial ap
– Abbe ap – Abbe + alar crescent ap – Nasolabial + buccal
Medial (alar) portion of
lateral subunit
– Alar crescent ap – Alar crescent – Free ap
Lateral portion of lateral
subunit
– Primary closure – Nasolabial + buccal
– Nasolabial ap (if
1
of upper lip
vermillion is intact)
1
Defect
Philtrum +/− alar portion of
lateral subunit
Lateral subunit – McGregor ap
– Alar crescent + cheek ap
Philtrum, lateral subunit, and
commissure
– Estlander + contralateral
– Nasolabial + buccal
–
of upper lip
3
mucosal ap
alar crescent ap
mucosal ap
Defect >
– Abbe + bilateral alar
2
of upper lip
crescent aps
mucosal ap
facial reconstruction, we recommend complete resection and subsequent reconstruction of the philtrum if more than 50% of the philtral subunit is involved. In our
experience, an Abbe ap can be used to adequately reconstruct the philtral subunit
and prevent a loss of normal denition in this area (Table5.6).
Local Flaps
Local aps are commonly employed in lip reconstruction. The basic principles of
local and locoregional aps have been discussed in earlier chapters. This section
aims to focus on specic aps described for lip reconstruction.
Bilateral Lip Advancement Flap
Bilateral lip advancement aps are useful for the reconstruction of full thickness
defects of both upper and lower lip defects.
For lower lip defects, an incision is marked out in the mental crease. Undermining
of the skin and muscle is performed prior to ap advancement. Partial thickness
incisions (sparing the mucosal layer) are often possible, given the innate elasticity
of the mucosa, but a full thickness incision can be carried out for larger defects. If
necessary, Burow’s triangles are excised at the lateral edge of the incision in the
mental crease bilaterally to prevent standing cone deformities (Fig.5.9). The aps
are then advanced, and multi-layer closure is then performed, adhering to the basic
principles discussed earlier in this chapter.
Bilateral upper lip advancement is typically performed using the alar crescent
ap technique, discussed in detail below.
5 Reconstruction oftheLip
75
ba
Fig. 5.9 Bilateral lower lip advancement ap
Stair-Step Advancement Flap
A variation of the lower lip advancement ap is the stair-step advancement ap,
described in the 1970s by Johanson and colleagues [30]. They described this ap as
a more functional and cosmetically appealing alternative to fan aps for defects
measuring up to two-thirds of the width of the lower lip.
The ap is designed for rectangular defects. Starting at the lateral edge of the
defect bilaterally, stepwise incisions are designed inferiorly and laterally. Small
squares of tissue are excised from the inferior aspect of the incision (under each
step) until the nal step, which is then excised as a triangle. The skin is undermined
and the aps are advanced, followed by a routine multilayer closure of the defect
and donor site incisions (Fig.5.10).
Alar Crescent Flap
Designed for the reconstruction of central upper lip defects, the alar crescent ap is
a single-stage procedure that permits the mobilization of skin and functional muscle
(if needed) with an intact neurovascular supply. This helps preserve normal sphincteric activity while providing a reasonable cosmetic result. It can be used for the
reconstruction of both partial and full thickness upper lip defects. The primary disadvantage to this procedure is the loss of philtral detail [31], especially in patients
undergoing bilateral aps for large central defects. For large upper lip defects, an
Abbe ap can be performed in conjunction with alar crescent aps, with the Abbe
ap used for the reconstruction of the philtral subunit (allowing the recreation of
this central anatomical detail).
The ap is designed by marking out an incision within the alar groove which is
extended inferiorly to connect with the defect (Fig. 5.11). A second incision is
designed lateral to this, creating a crescent shaped piece of tissue that is excised in
order to prevent distortion of the perialar region with advancement of the ap. Wide
subcutaneous undermining of the lip and cheek tissue is then performed. The ap is
76
ab
Fig. 5.10 Stair-step ap
S. Kohlert
c
then rotated and advanced to ll the defect. Multilayer closure is performed.
Bilateral aps can be performed to repair large defects that cannot be repaired with
a unilateral ap alone.
Karapandzic Flap
Initially described in 1974, Karapandzic developed this ap as a surgical option for
patients with poor vascular supply including radiated patients and the very elderly
[32]. This circumoral ap design was unique compared to prior techniques (such as
the Gillies fan ap discussed below) through the use of partial thickness incisions
and blunt dissection for neurovascular preservation. It remains in use today as an
option for the correction of upper or lower lip defects involving more than half of
the lip. The major concern with this ap design is microstomia, with 22% (13/58) of
patients in the original case report requiring later surgical correction of their signicantly reduced oral circumference. Blunting of the external commissure is very
common and may require subsequent commissuroplasty.
For lower lip defects, the inferior aspect of the incision is designed within the
mental crease to improve cosmesis. It is extended bilaterally in a circumoral fashion
and carried superiorly along the nasolabial fold, typically terminating just inferior
and lateral to the nasal ala (Fig.5.12). A similar incision is designed for upper lip
defects, without the inferior incision through the mental crease. The incisions are
then carried out in a partial thickness fashion. Blunt dissection is performed in the
orientation of the vessels in order to mobilize the tissue while preserving the
Bilateral
5 Reconstruction oftheLip
Orbital rim
Extent of flap
undermining
77
Second
crescenteric
incision
Unilateral
Fig. 5.11 Alar crescent aps (unilateral and bilateral)
neurovascular structures. Karapandzic described the ap without any long mucosal
incisions, although separate mucosal incisions can be carried out if there is not
enough elasticity of the mucosa to permit sufcient ap mobilization after complete
dissection. Precise multilayer closure is then carried out. Postoperative microstomia
can often be addressed with lip-stretching devices (as discussed in the complications section below).
Multiple modications of the Karapandzic ap have recently been described for
the successful reconstruction of even larger defects. Hanasono and Langstein
described a modication which recruits perioral cheek tissue to help reconstruct
these large defects while maintaining normal or near normal mouth opening [33]. A
subsequent series of 21 patients by Dediol and colleagues went further, using extensions of the ap to the medial canthus bilaterally to successfully reconstruct near
total defects of the lip and chin [34].
78
S. Kohlert
Fig. 5.12 Karapandzic ap
5 Reconstruction oftheLip
79
Gillies Fan Flap
The Gillies fan ap was designed in the early-to-mid-twentieth century as an option
for the reconstruction of full thickness lower lip defects [35].
Flap design is relatively simple. A full thickness incision is carried laterally from
the inferior aspect of the incision around the oral commissure and extended superiorly along the nasolabial fold. A 60-degree back cut is then performed medially
towards the ipsilateral oral commissure. The ap is rotated, and multilayer closure
is performed in the usual fashion (Fig.5.13).
Given that this technique involves full thickness incisions through the skin of the
lower lip and part of the upper lip and can consequently result in prolonged anesthesia of the lip, it also tends to lead to the distortion of the commissure, often requiring
additional surgical intervention in the future. Bilateral Gillies aps can be performed but tend to result in signicant microstomia [36].
Bernard–von Burow (and Webster Modification)
In the mid-nineteenth century, Bernard [37] and von Burow [38] separately described
a ap involving bilateral full thickness cheek advancement aps. Multiple triangles
of skin and subcutaneous tissue (“Burow’s triangles”) are excised, two for lower lip
reconstruction (three including the defect) and four for upper lip reconstruction
(Figs.5.14 and 5.15) to prevent standing cone deformities. Full thickness advancement of the cheek skin is then performed bilaterally.
In 1960, Webster and colleagues described a modication of the Bernard–von
Burrow ap for total lower lip reconstruction [39]. The Webster modication of this
ap provides an improved aesthetic outcome by altering the shape and orientation
of the superior Burow’s triangles to better place the scars within natural skin creases
(the nasolabial folds). Furthermore, while the Bernard–von Burow technique for
lower lip reconstruction involves a third Burow’s triangle through the aesthetic
Fig. 5.13 Gilles fan ap
ba
80
ba
Fig. 5.14 Bernard–von Burow ap for lower lip reconstruction
ba
S. Kohlert
Fig. 5.15 Bernard–von Burow ap for upper lip reconstruction
subunit of the chin, the Webster design replaces this with two lateral wedges excised
from around the cicummental crease (Fig.5.16), which tends to place the scars near/
at the marionette lines.
While effective for subtotal and total lip reconstruction, these bilateral cheek
advancement aps have multiple drawbacks. First, given that the donor site is the
cheek (as opposed to native lip tissue), there is no orbicularis oris included in the
ap and therefore the normal orbicularis sphincter is not restored. Additionally, the
full thickness incisions described in the above techniques can result in neurovascular compromise, and signicant postoperative sensory disturbance in the
ba
5 Reconstruction oftheLip
Fig. 5.16 Webster modication
81
surrounding area may ensue. A more challenging technique involving partial thickness incisions through skin and subcutaneous tissue with meticulous subcutaneous
dissection can mitigate this risk [40].
Local Flaps: Cross-Lip Flaps
Early descriptions of cross-lip aps (by Sabattini and subsequently by Stein) date
back to the mid-nineteenth century [41–43]. Further modications of this ap were
subsequently published by Estlander and Abbe in 1872 [44] and 1898 [45], respectively, and have remained critical options in the facial reconstructive surgeon’s arsenal ever since. Cross-lip aps can be employed (alone, or in conjunction with other
local aps) for the reconstruction of large defects that would result in signicant
transverse lip tightness and microstomia if repaired via other techniques.
Furthermore, the Estlander cross-lip ap design is the workhorse ap for the reconstruction of medium-to-large defects involving the oral commissure.
Abbe Flap
The Abbe ap is commonly used for the reconstruction of medium-to-large defects
of either lip where the commissure is spared. It is based on the labial artery (with
venous drainage through its venae comitantes) and can be pedicled either medially
or laterally. The ap typically includes a vermillion lip and cutaneous lip component. A classic Abbe ap can be used for lip defects measuring up to 60% of the
total lip length upper lip length [46] and in our experience has been successfully
used for even larger defects of the lower lip. Sensory and motor decits do occur
initially in the transferred lip. Early recovery begins within 2 to 3months of the
procedure, with near normal recovery expected by 12 to 18months [47–49].
The width of the designed ap is typically designed to measure 50% of the width
of the defect, ensuring that the widths of the upper and lower lips remain proportional after ap division. Exceptions do exist; for example, we will elevate a ap of
82
S. Kohlert
the same width as the defect for the reconstruction of an entire subunit (such as the
philtrum). The height of the cutaneous component of the ap should be made to
match the height of the cutaneous defect. A full thickness incision is planned
through the lip on the non-pedicled side. Prior to carrying out the incisions, the
white roll should be marked on both lips to facilitate accurate inset. The incisions
are then carried out in a full thickness fashion (except for the pedicled side). The
ap is then rotated into the defect (Fig.5.17). On rare occasions, it is necessary to
make an incision through the inferior aspect of the vermillion of the pedicled side to
facilitate rotation. This maneuver is safe as long as the surgeon does not breach the
orbicularis oris muscle (the pedicle runs between the muscle and the labial mucosa).
After satisfactory rotation, the ap is then inset into the defect site, ensuring to carefully repair the muscular layer and align the previously marked white roll.
Division and inset are typically performed 2 to 3weeks after the initial procedure. We prefer to delay the division of the ap for up to 4 to 6weeks in cigarette
smokers to reduce the risk of vascular compromise.
Extended Abbe Flap
The extended Abbe ap was described by Kriet and colleagues in 1995 as a method
of addressing large upper lip defects. Thanks to the course of the vertical labiomental branch of the labial artery, this ap can be designed to extend into the submental
area and can provide both a wider and longer ap [46] (Fig. 5.18). It has been
employed for the reconstruction of defects measuring more than 60% of the horizontal lip length, as well as taller upper lip defects extending into the medial cheek.
Estlander Flap
First described by Estlander in 1872 [44], this ap is an excellent choice for the
reconstruction of signicant defects (typically those impacting one-third to twothird of the lip) with the involvement of the oral commissure. It can be used for
defects involving either lip.
The ap is designed on the opposite ipsilateral lip. The width of the ap on the
donor vermillion lip is designed to measure half of the width of the defect. A wedge
of cutaneous lip is also included for the reconstruction of any skin defect on the
involved lip. The incisions are then carried out in a full thickness fashion. Medially,
the incision is carried down to the white roll which facilitates mobilization and rotation of the ap while minimizing the risk of injury to the contralateral labial artery
(upon which this ap is pedicled). If additional dissection must be done beyond the
white roll/vermillion border to allow for adequate rotation, it should be done meticulously and without the use of cautery to avoid inadvertent vascular injury. Once the
opposite ipsilateral lip has been adequately mobilized, it is then rotated by 180
degrees and inset into the defect in a multilayer fashion as discussed above.
Blunting of the oral commissure is a common sequela of this procedure, and
many patients will require secondary commissuroplasty (which is further discussed
in the Complications of Lip Reconstruction section below).
5 Reconstruction oftheLip
83
Fig. 5.17 Abbe ap
Free Tissue Transfer
Radial Forearm Free Flap
Very large defects (especially those involving the majority portion of the lip as well
as the surrounding tissue) can be challenging, if not impossible, to reconstruct with
the use of local/logo-regional aps. In these cases, microvascular reconstruction can
be a valuable tool. Thanks to its pliability, versatility, and reliable blood supply with
a long vascular pedicle, the radial forearm free ap (RFFF; see chapter ___ in this
text) is the most commonly employed free ap in lip reconstruction. A composite
ap consisting of the skin paddle along with the palmaris longus may be harvested
to help achieve a static suspension of lip, assisting with oral competence. First
described in 1989 [50], this modication of the RFFF provides improved cosmetic