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4 Patient-Specic Implants andProsthetics
13. Kesting MR, Koerdt S, Rommel N, Mücke T, Wolff KD, Nobis CP, Ringel F, Frohwitter
G. Classication of orbital exenteration and reconstruction. J Craniomaxillofac Surg.
2017;45(4):467–73. https://doi.org/10.1016/j.jcms.2017.01.003.
14. Su GW, Yen MT.Current trends in managing the anophthalmic socket after primary enucleation and evisceration. Ophthal Plast Reconstr Surg. 2004;20(04):274–80.
15. Lin CJ, Liao SL, Jou JR, Kao SC, Hou PK, Chen MS, Complications of motility peg placement
for porous hydroxyapatite orbital implants. Br J Ophthalmol. 2002;86:394–6.
16. Cervelli V, Bottini DJ, Arpino A, Colicchia GM, Mugnaini F, Trimarco A, Gentile P, Grimaldi
M.Orbital reconstruction. J Craniofac Surg. 2006;17(5):848–53. https://doi.org/10.1097/01.
scs.0000229556.04953.fa.
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Reconstruction oftheLip
ScottKohlert
Introduction
Lip defects are commonly encountered by facial reconstructive surgeons. Common
causes include congenital abnormalities [1], facial trauma [2], and neoplastic disease. Carcinoma of the lip is one of the most frequently encountered malignancies
in the head and neck [3]. Surgical resection is the primary treatment modality of lip
cancer and can result in signicant defects of the lips and surrounding tissues.
Anatomy
While excellent outcomes are often easily achieved for small defects, large labial
defects can be challenging to reconstruct, given the anatomical complexity in this
location. The lip is a complex multilayered structure consisting of mucosa, submucosa, muscle, subcutaneous tissue, and skin. A detailed understanding of the underlying anatomy is critical in order to successfully restore form and function after a
major lip reconstruction.
5
Surface Anatomy oftheLip
The outer surface of the lip is divided into visibly distinct parts: the mucosal lip
(also known as the vermillion or the red lip) and the cutaneous lip (sometimes
referred to as the white lip). Each should be reconstructed with similar tissue if the
surgeon wishes to obtain the best possible result. The transition point between the
S. Kohlert (*)
CHRISTUS Health, Tyler, TX, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_5
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62
Cupid’
)
White roll
Cutaneous
(white) lip
Vermillion
border
s Bow
Fig. 5.1 Surface anatomy of the lip
S. Kohlert
Philtral column
Philtral dimple
Oral
commissure
Vermillion (red
lip
vermillion and the cutaneous lip is known as the vermillion border (Fig.5.1). This
border reects light and has been shown to be a common gaze xation point in eyetracking studies [4]. Accordingly, careful reapproximation of this area is paramount
in lip reconstruction [5] as any deformity or disruption of the border is easily perceived by both professionals and laypeople alike [6].
Anatomical Subunits oftheLip
As with other aesthetic units of the face, the lips can be further divided into unique
topographical subunits. While the lower lip is often considered as a single unit,
Burget and Menick [7] long ago described the upper lip as having multiple subunits:
a central philtrum, along with paired lateral subunits (Fig.5.2). The philtrum is
located centrally in the upper lip and is bound superiorly by the columella and part
of the nasal sill, laterally by the philtral columns and inferiorly by Cupid’s Bow.
Each lateral subunit is divided into two separate components. The medial component is the part that sits inferior to the nasal sill and measures approximately one
half of the width of the philtrum. The philtrum and the medial component of the
lateral subunit are similar in so far as they are relatively more xed to the surrounding structures (such as the maxilla and the nose) and are thus less mobile than the
lateral component of the lateral subunit [8]. The lateral component extends
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ease
5 Reconstruction oftheLip
63
Philtral ridge
Medial element
Lateral element
Nasolabial cr
Fig. 5.2 Subunits of the upper lip
superiorly along the alar-facial groove and laterally to the nasolabial fold. As with
any other facial reconstruction, careful attention must be paid to the involved subunits, and, if possible, each involved subunit should be managed individually to
improve the cosmetic outcome. Additionally, when the majority of a subunit has
been resected, one will often obtain a superior result if the remainder of the subunit
is resected prior to reconstruction [7].
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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
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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,
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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.
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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).
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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)
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– Healing by secondary intention
– Primary closure
– Vermillion advancement ap
– FAMM ap
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