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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)
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– 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
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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
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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
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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
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3
3
2
3
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.
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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
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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
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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].
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S. Kohlert
Fig. 5.12 Karapandzic ap
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