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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
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Fig. 5.14 Bernard–von Burow ap for lower lip reconstruction
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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
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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
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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).
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5 Reconstruction oftheLip
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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
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border
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Excise
Preserve
vermilion
Fig. 5.18 Extended Abbe ap
skin
Abbe flap extends
to inferior chin
advancement
Extended
Abbe flap
Cheek
and functional results for patients with large-scale defects of the lip and chin [51,
52], although there have been reports of long-term loss of oral competence in cer-
tain patients [16].
Modications to the RFFF technique aimed at providing dynamic reconstructions of major lip defects. Grinsell and Herle recently described a composite procedure including an innervated pronator quadratus muscle ap coapted to the buccal
branch for motor innervation and to the mental nerve (in lower lip reconstruction)
or infraorbital nerve (upper lip reconstruction) for sensory input [53].
Alternative Donor Sites forFree Tissue Transfer
While the RFFF is the workhorse for total lip and chin defects, other donor sites are
occasionally used for free tissue transfer as well. Functional gracilis muscle aps
(covered by split thickness skin grafts) can be employed for total lip defects. Studies
have demonstrated satisfactory cosmetic and functional outcomes (with clinical
recovery of sensation to the ap as well as normal pattern motor unit potentials in
the muscle on postoperative needle electromyography studies with this technique)
[54]. Composite defects of the lip and mandible can be reconstructed with osteocutaneous aps from a wide array of donor sites including the radial forearm, bula
[55], scapula [56], and latissimus dorsi with rib [57, 58]. While anterolateral thigh
aps have traditionally been felt to be too bulky for lip reconstruction, “super-thin”
ALT aps have been successfully employed for large lower lip and skin defects with
good success [59]. Details regarding the harvest of many of these aps can be found
in the later chapters of this text.
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5 Reconstruction oftheLip
85
Complications ofLip Reconstruction
Complications of lip reconstruction can be divided into short-term and long-term
complications. Short-term complications include pain, infection, wound dehiscence, difculty tolerating a normal diet, ap failure, numbness of the surrounding
area (temporary or permanent), and need for additional surgery. Long-term complications include poor cosmetic result, microstomia (which may impair the patient’s
ability to wear dentures or eat certain foods), abnormal mobility of the lips/facial
muscles, dysarthria, and permanent loss of oral competence (and associated drooling). The risk of many of these complications is mitigated by a proper choice of
reconstructive method and meticulous operative technique, although not all can be
avoided completely (especially in patients presenting with very large and complicated defects).
Managing Microstomia
While the risk can be mitigated, microstomia is a somewhat common complication
of major lip reconstruction, especially in patients with large defects. In our practice,
signicant improvement is often seen when following therapy with a combination
of manual massage techniques, orofacial exercises, as well as the use of formal oral
stretching devices. A wide array of oral appliances have been developed throughout
the years [60]. We employ the Therabite® rehabilitation system (Atos Medical; New
Berlin, WI) for our patients with microstomia and trismus. Unfortunately, the
Therabite® can be prohibitively expensive for many patients, and we often employ
a modication of the thermoplastic mouth stretcher described by Dougherty [60,
61] for home-based exercises in this population.
Commissuroplasty
Blunting of the oral commissure is a potential complication of lip reconstruction,
especially when the defect involves the oral commissure. Given the nature of the
Estlander and Karapandzic aps, blunting is frequently observed after these procedures. Oral commissuroplasty can be performed secondarily to improve the cosmetic result.
There are two primary techniques for commmissuroplasty: buccal mucosal
advancement and myomucosal advancement (of the labial mucosa and the underlying orbicularis oris). Both approaches begin with a triangular-shaped resection of
the skin lateral to the blunted oral commissure, with the apex of the triangle in the
location of the expected position of a normal commissure.
The simpler of the two techniques (and our preferred approach) is the buccal
mucosal advancement ap technique. After wedge resection of the skin lateral to the
blunted commissure, the vermillion over the commissure is excised, and the underlying orbicularis oris is divided horizontally through the commissure. The upper
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Mucous memb.
incisions
Fig. 5.19 Oral commissuroplasty
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and lower muscle edges are then advanced and attached to the skin at the apex of the
previously excised triangular wedge (Fig.5.19). Buccal mucosa is then advanced
over the top of the muscle and secured to the skin with resorbable suture.
A full description of both approaches has been well described in an excellent
review article by Parsel and Winters [62].
Summary
Lip defects are commonly encountered by the head and neck reconstructive surgeons. Neoplasia, trauma, and congenital abnormalities are the most common causes.
There are a wide array of reconstructive options available for upper and lower lip
reconstructions that span the length of the reconstructive ladder. The surgeon should
carefully assess the defect (including which subsites are involved) and select the
least complex reconstructive option available that will result in a satisfactory cosmetic and functional result. Complications of reconstruction include poor cosmetic
result, temporary and/or permanent loss of sensation, impaired motor function and
loss of oral competence, dysarthria, and microstomia. A careful ap selection and
meticulous surgical technique can mitigate the risk of these complications.
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