Reconstruction of acquired lip defects

Anatomy-

Philtral column

Philtral groove/dimple

Cupids bow

White roll- junction of vermillion and cutaneous surface

Tubercle

Commissure

Vermillion – the red/pink dry part of lip seen outside

 

Vermillion is widest in central lip

Philtrum columns are formed by C/L orbicularis oris fibers.

Philtrum columns slightly diverge as then come down.

White roll created by pars marginalis fibers of orbicularis oris.

 

Upper lip elevators-

1. Z. major
2. Z. minor
3. LLS AN
4. LLS
5. LAO

[levator labii superioris anguli nasalis, levator labii superioris anguli, levator  anguli oris]

Retractors and depressor of lower lip-

1. Platysma
2. Depressor labii
3. Depressor anguli oris

Lower lip elevator– Mentalis (makes pout)

Nasolabial crease formed by-

1. Z. major
2. LLS
3. LAO

 

Orbicularis oris-

Two components-

1. Pars marginalis
2. Pars peripherlais

Marginalis anterior to peripherialis [Peripheralis- Posterior]

Marginalis mostly deep to vermillion area

Peripheralis mostly deep to cutaneous portion of lip

 

Muscular sling that presses lip against gingiva and teeth is formed by-

1. Orbicularis
2. Risorius
3. Buccinator
4. Pharyngeal constrictor

 

Blood supply-

Facial artery courses through a plane which between two muscle layers.

Muscles anterior/superficial to artery are-

1. Risorius,
2. Z major,
3. Superficial lamina of orbicularis oris (OO)

Muscles that are deep to the artery are-

1. Buccinator,
2. LAO,
3. Deep lamina of OO

Facial artery branches approx- 1.5cm lateral to oral commissure

Into – superior labial and inferior labial a.

Superior labial- found within 10mm of lip margin

Inferior labial- found within 4-13 mm of lip margin

 

Labial artery lies within or posterior to orbicularis oris muscle but Never anterior to it.

 

Nerve supply-

Motor-

Zygomatic and buccal branch – lip elevators and retractors

Marginal mandibular- lip depressor

Sensory-

V2 –infraorbital & V3 mental branch of trigeminal nerve

 

Etiology of lip defect –

Most common cause is – Carcinoma lip. MC type of cancer is Squamous cell ca.

96% lip cancer occur in lower lip

96% is SCC type.

96% of patients are male.

 

Reconstruction – defect wise

Vermillion-

Defect by definition does not crosses white roll.

So, reconstruction should – Avoid crossing white roll.

Simplest method—undermining of adjacent oral mucosa with defect closure by advancement.

Wilson & Walker – laterally based bipedical mucosal flap

For Full-thickness defect of vermillion –

-lateral vermillion musculomucosal advancement flap (based on labial artery)

-musculocutaneous flap composed of intraoral mucosa and orbicularis advanced from sulcus in V-Y fashion

Other regional flaps-

Unipedicle vermillion lip switch flap from opposite lip -divided after 10-14 days

Random musculomucosal flap

FAMM flap (facial artery myomucosal flap) – buccinators muscle based on facial artery

Tongue flap (from lateral/lower surface) – two stage procedure cumbersome.

 

Partial thickness defect-

Primary closure

Advancement flap

Transposition flap

Skin graft not routinely used/required

Except, central philtral defect- full thickness graft used instead of STSG.

 

Small full thickness defect-

Primary closure-

Lower lip- up to 40% defect

Upper lip- up to 25 % defect

 

Large full thickness defect-

Two resources to recruit extra tissue to fill the defect – opposite lip & adjacent cheek.

Orbicularis oris- better competent stoma. Microstomia a risk.

Cheek- microstomia less common, functionally and aesthetically inferior outcome

 

Large central upper lip defect-

Abbe flap (based on inferior labial artery)  –> flap division after 2-3 weeks

Abbe flap with perioral crescent

 

Large central lower lip defect-

B/L Karapandzic

Modified Bernard (Webster- Bernard)

Nasolabial flap

 

Karapandzic	Bernard
Musculocutaneous rotation advancement flap Neurovascular flap First 1cm incision full thickness- after that only skin and muscle divided, mucosa is intact Burrow’s triangle excised	Lateral advancement flap First 1cm full thickness incision after that only skin and mucosa intraorally Burrow’s triangle excised

 

Interdigitating nasolabial flap

Partial thickness random flap

Full-thickness “Gate-flap”- based on facial a

Full thickness flap denervates upper lip.

 

Large lateral and commissure defect-

Estlander-

Medially based rotation advancement flap from upper lip to lower lip

Reverse Estlander- from lower lip to upper lip

Gillies-fan flap- rotational advancement flap. A quadrilateral flap

McGregor & Nakajima modified fan flap –

1. Pivotal flap
2. Stoma size unchanged
3. Need for vermillion reconstruction

Abbe-Estlander flap-

Preserves commissure

Need second stage of flap division

Temporary microstomia

U/L Karapandzic

U/L Bernard

U/L Nasolabial flap

 

Total lip reconstruction-

>80% defect-

B/L Bernard or Nasolabial flap

Submental flap (flap based on submental branch of facial artery)

Radial forearm free flap (RAFF)

Karapandzic – will cause microstomia, so not preferred.

RAFF is the best choice for total lip reconstruction.

Palmaris longus tendon can be harvested along with the flap to be weaved into remaining OO muscle or into modulus.

 

Lip replantation –

Uncommon

Most commonly – by traumatic amputation by dog bite.

Every attempt should be made for reimplant as the aesthetic and functional outcome is better than free tissue transfer.

Main obstacle in reimplant of lip is – poorly formed labial vein.

 

 

 

Algorithm –

Defect size	Defect location	Reconstructive option
Up to 25% – upper lip Up to 40% – lower lip		Primary closure
25-80 %	Upper lateral lip or lower lateral lip	Lip switch (Estlander/Abbe) or Unilateral Karapandzic/ Bernard/ Nasolabial flap
	Central lower lip	Bilateral Karapandzic/ Bernard
	Central upper lip	Abbe flap +/- perioral crescent
>80%		Bilateral Bernard/ Nasolabial flap or Free tissue transfer – RAFF

(further reading – Grabb and Smith Plastic surgery 7th Ed. chapter 34)