5. Lip reconstruction
Anatomy
Motor Innervation
Facial nerve VII
Buccal
Elevators of commissures and orbicularis oris
Marginal mandibular
Lip depressors
Sensory innervation
Trigeminal nerve V
Mental nerve terminal branch of inferior alveolar nerve
Lower lip
Infraorbital nerve
Upper lip
6. Lip reconstruction
Anatomy
Muscles
Orbicularis oris
Closes the oral sphincter
Primarily horizontal fibers - compress lips
Originate lateral to the commissures
Mingle with cranial VII muscles at modiolus
Cross the lip
Decussate in the midline
Insert into opposite philtral column
Oblique fibers - evert lip
Arise from modiolus
Travel upward and medial
Insert at the anterior nasal spine, nasal septum, and anterior nasal
floor
7. Lip reconstruction
Anatomy
Muscles
Major elevators upper lip
Levator labii superioris (LLS)
Originates from orbital margin
Curves around the alar base
Inserts into ipsilateral orbicularis oris and philtral column
Zygomaticus major
extends from malar eminence inserts in modiolus
Levator anguli oris
arises just below the lateral edge of the LLS
8. Lip reconstruction
Anatomy
Muscles
Nasalis muscle
Three components
Arise from bone below the piriform aperture
Depressor septi muscle is the most medial of the three. This
paired muscle arises from the periosteum over the central and
lateral incisors to insert cephalad into the footplates of the
medial crura (Fig. 2). Its function is primarily the depressing of
the tip of the nose and secondarily the lifting of the upper
central lip. The nasalis muscle alar part sends fibers to the ala
and the nasalis transversus part to the nasal dorsum19.
9. Lip reconstruction
Anatomy
Muscles
Mentalis muscle
Paired
Function primarily in the elevation and protrusion of the central
aspect of the lower lip. They arise from about 2 cm of alveolar
periosteum just below the vestibular sulcus and descend obliquely to
insert into the skin of the chin.
Loss of these muscles below the labiomental area
following resection, mucosal scarring, or inadequate
muscle suture technique results in lip incompetence and
lower incisor “show”
10. Lip reconstruction
The depressor labii inferioris (quadratus) arises from the lower
border of the mandible between the symphysis and the mental
foramen. The fibers pass upward and medially, intermingling
superiorly and more medially with the orbicularis oris. This muscle
displaces the lower lip inferiorly. The depressor anguli oris
(triangularis) arises inferior to the quadratus muscle and continues
upward to the modiolus. At its origin, the muscle mingles with the
platysma fibers. It functions to help draw the angle of the mouth
downward and laterally.
11. Lip reconstruction
Anatomy
Vascular supply
Derived from the facial arteries
Superior and inferior labial branches
Travel tangentially deep to the orbicularis oris muscles
Lymphatic drainage
Primarily submental and submandibular nodes
Upper lip and lateral lower lip
Submandibular chain
Central lower lip
Submental nodal area
Crossover common
12. Lip reconstruction
Approach
Evaluate
Size and location of the defect
Etiology of the lesion
Patient age and gender
13. Lip reconstruction
Surgical goals
Complete skin cover and oral lining
Semblance of a vermilion
Adequate stomal diameter
Sensation
Competent oral sphincter
14. Lip reconstruction
Vermilion
Modified mucosal surface
Most visible component of the lips
Sensory unit of the lips
Temperature
Light touch
Pain
Scars well hidden at vermilion
Avoid crossing vermilion cutaneous junction
Incisions should cross at 90 degrees
1 mm discrepancy in outline of white roll visible at 3 feet
15. Lip reconstruction
Vermilion reconstruction
Lower vermilion most affected
Target of solar radiation injury
Premalignant lesions
Actinic cheilitis or leukoplakia
Total vermilionectomy (lip shave)
Resection from white roll to contact area with opposite lip
Primary closure possible
Tension and dehiscence
Flattening of lip
16.
17. Lip reconstruction
Vermilion reconstruction
Buccal mucosal advancement flap
Relaxing incision on mucosa at deep buccal sulcus
Mucosa elevated deep to salivary glands and superficial to
orbicularis oris muscle
18. Lip reconstruction
Vermilion reconstruction
Tongue flaps
Two stage procedures
Tongue mucosa
Red with poor cosmetic match
Feminizing effect in men
Unpleasant experience for patients
19. Lip reconstruction
Vermilion reconstruction
Vermilion muscle advancement flap
Defect less than 1/3 lower vermilion
Based on axial labial artery
20. Lip reconstruction
Vermilion reconstruction
Lip switch (Kawamoto)
Correction of large vermilion volume deficiency
Hemifacial atrophy
Transverse centrally based flap
Turn 180 degrees
Pedicle divided
10-14 days
21.
22. Lip reconstruction
Lower lip
Advantage over upper lip
Increased soft tissue laxity
No dominant central structure
Philtrum
Nose
Disadvantage
Effect of gravity on repair
Greater need for tone to prevent drooling and oral
incompetence
23. Lip reconstruction
Lower lip reconstruction
Primary closure
V or W wedge resection
Can provide inadequate margin at lower portion of resection
Shield or double or single barrel excision
Avoid crossing the labiomental fold
Improves aesthetic result
Grafts
Unreliable survival of composite grafts
Average width 1 cm
27. Lip reconstruction
Lower lip
reconstruction
Step method
Horizontal component
of step excisions
½ width of defect
Vertical dimension
8-10 mm
2 to 4 steps are made
Can be used to close
defects up to 2/3 of lip
length
28. Lip reconstruction
Lower lip reconstruction
Abbe flap
Lip switch
Two stage procedure
14-21 days of lip apposition before pedicle division
Indications
Medium sized defects
Defect not involving commissure
Cooperative patients
EMG studies
Return of muscle function to flap at recipient site
29. Lip reconstruction
Lower lip reconstruction
Abbe flap
Flap design
Junction of middle and lateral 1/3s of upper lip
Away from philtral columns and commissure
Paper template useful
Medial or lateral pedicle
Distal flap
Tapered to nasolabial fold
Rectangle
Maximum flap size
2 to 3 cm
30.
31. Lip reconstruction
Lower lip reconstruction
Abbe flap
Flap elevation
White roll marked
Full thickness division of non pedicle side
Locate exact position of labial artery
Allows precise dissection on pedicle side
Vascular pedicle should have soft tissue support
Post operative
Liquid and soft diet
Antiseptic rinses
Pedicle division at 2 to 3 weeks
33. Lip reconstruction
Lower lip reconstruction
Estlander flap
Laterally based lip switch
Pivots at corner of mouth
Indications
Defect at commissure
Advantages
Maintains continuity of orbicularis oris
Oral competence
Disadvantages
Poor commissure definition
Needs secondary revision
34. Lip reconstruction
Lower lip reconstruction
Estlander flap
Flap design
Full thickness
Medial based flap of lateral lip
Supplied by contralateral labial artery
½ size of lower lip defect
Distal edge of flap tapered to nasolabial fold
35. Lip reconstruction
Lower lip
reconstruction
Estlander flap
Modified Estlander
Transposition of flaps
Preserves commissure
Estlander flap with
medial advancement of
lateral lip
Large central defects
36. Lip reconstruction
Lower lip reconstruction
Fan flap
Indications
Total or near total lower lip reconstruction
Gillies fan flap
Modification of Estlander flap
Preservation of portion of oral sphincter
EMG confirmed nerve regeneration
37. Lip reconstruction
Lower lip reconstruction
Karapandzic flap
Indications
Modification of Gillies fan flap
Defects not requiring new lip tissue
Central
3.5 to 7.0 cm defects
Lateral with commissure involvement
Preservation of neurovascular supply
Oral sphincter function maintained
38. Lip reconstruction
Lower lip reconstruction
Karapandzic flap
Advantages
Sensation and sphincter function
Preferable to Bernard Burow’s repair
Single stage procedure and less risk of flap loss
Compared to Abbe flap
Disadvantages
Microstomia
Inferior aesthetic result
Circumoral scarring noticeable
39. Lip reconstruction
Lower lip reconstruction
Karapandzic flap
Flap design
Vertical height of defect
Determines width of flap
Width maintained to alar bases
Full thickness incision medially
Laterally at level of commissures
Incision to subcutaneous tissue
Labial arteries and buccal branches dissected and preserved
Central defect equal mobilization
Lateral defect contralateral mobilization greater
40. Lip reconstruction
Lower lip reconstruction
Depressor anguli oris flap
Innervated motor and sensory flap
Muscle, skin, buccal mucosa
Marginal mandibular VII and mental branch V
Based superiorly at oral commissure
Limited to lateral lower lip reconstruction
Reach of mental nerve restricts
Bilateral flaps can be raised
41.
42. Lip reconstruction
Lower lip reconstruction
Bernard Burow’s procedure
1st described
Full thickness excision 4 triangles
Two have caudal base at commissure
43. Lip reconstruction
Lower lip reconstruction
Bernard Burow’s procedure
Modifications (Webster)
Excise skin and subcutaneous tissue
Leave muscle intact
Base triangle in nasolabial fold
Paramental triangular flaps
44. Lip reconstruction
Lower lip reconstruction
Bernard Burow’s procedure
Indications
Need for new lip tissue
Avoidance of microstomia
Advantages
Brings new tissue from cheek
Commissure better reconstructed
Disadvantages
Incomplete recovery of sensation
Vermilion color mismatch
Oral incontinence and drooling
45. Lip reconstruction
Lower lip reconstruction
Bernard Burow’s procedure
Flap design
Excision of lower lip lesion
Triangles of skin and subcutaneous tissue
Excised at nasolabial fold
Buccal mucosa undermined
All layers advanced and approximated
47. Lip reconstruction
Lower lip reconstruction
Nasolabial flaps
Inferiorly based
Pivot on the commissures
Mucosa lining flaps
Everted to recreate vermilion
48. Lip reconstruction
Lower lip reconstruction
Free flaps
Radial forearm most common
Ease of dissection
Two team approach
Thin, pliable, hairless and good colour match
Can integrate palmaris longus tendon
Attach to modiolus as a sling
Avoid oral incompetence
Can attach to malar eminence with microplate
49. Lip reconstruction
Lower lip reconstruction
Rational approach
Based on extent of defect
Small (less than 1/3)
Primary closure
Medium (1/3 to 2/3)
Karapandzic
Estlander
Abbe
Bernard Burow’s
Large (greater than 2/3)
Bernard Burow’s
Karapandzic
Free flap
50.
51. Lip reconstruction
Upper lip
Defects less common
Unique features to consider
Nose
Columella
Cupid’s bow
Philtrum
Men
Hairbearing – nasolabial and cheek flaps obvious
Can disguise scars in a mustache
Oral competence less significant
52. Lip reconstruction
Upper lip
Aesthetic subunits
Lateral
Philtral column
Nostral sill
Alar base
Nasolabial crease
Medial
One half of philtrum
Popularized by Burget and Menick
Design Abbe flaps exactly to match subunit
61. Lip reconstruction
Upper lip reconstruction
Inverted Bernard Burow’s flap
Upper lip defect replaced with midcheek tissue
Skin and subcutaneous tissue Burow’s triangles excised lateral
to the lower lip and alar base
Orbicularis muscle not violated
Vermilion reconstructed with buccal mucosa
62.
63. Lip reconstruction
Upper lip
reconstruction
Bilateral levator
anguli oris flap
Innervated
Bilateral and combined
with Abbe flap
Can be used for total
lip reconstruction
64. Lip reconstruction
Upper lip reconstruction
Rational approach to upper lip reconstruction
Small (less than 1/3)
Medium (1/3 to 2/3)
Large (greater than 2/3)
74. Cheek reconstruction
Introduction
Aesthetic units
Zone I
Suborbital
Zone II
Preauricular
Zone III
Buccomandibular
Includes oral lining in
full thickness defects
75. Cheek reconstruction
Zone I
Boundaries
Medial: nasolabial line
Lateral: anterior sideburn
Inferior: gingival sulcus
Superior: lower eyelid
Subunits
A, B & C
Subunit C consists of lower
eyelid skin at junction with
cheek skin
Orbicularis and zygomaticus
origin
VII deep to zygomaticus
76. Cheek reconstruction
Zone I
Skin grafts
Split thickness skin grafts
Unfavorable contraction
Ectropion and lid malposition
Full thickness skin grafts
Preauricular, postauricular, supraclavicular region
Better suited lower eyelid (subunit C)
Less contraction
Subunit A and B – patchy result
Poor contour replacement if defect >5mm depth
77. Cheek reconstruction Zone I
Local flaps
Rhomboid flap
8 flap options
Donor site scar
Direction of relaxed skin tension lines
Base flap inferiorly
Decreased edema
Minimize trapdoor effect
78.
79. Cheek reconstruction
Zone I
Local flaps
Swing side plasty
Reduces size of defect
Minimize flap
ischemia by rounding
tip
Avoid narrow distal
tip
80. Cheek reconstruction
Zone I
Cervicofacial flap
More extensive zone I defects
Subcutaneous plane
Extensive dissection unreliable vascularity
Transection of transverse branch facial artery
Deep plane
Beneath SMAS (subplastymal in neck)
Facial nerve injury significant risk
Useful in smokers and larger flaps
Anchoring sutures
Anterior zygomatic arch and orbital rim
Tissue expansion
Congenital nevi
81.
82. Cheek reconstruction
Zone II
Superolateral
junction of helix and
cheek
Medially to malar
eminence
Inferior to mandible
Covers
parotid/masseteric
fascia
83. Cheek reconstruction
Zone II
Skin grafts
Skin laxity in zone II
Common donor site
Use of skin graft rare
Camouflaged easily with hair
84. Cheek reconstruction
Zone II
Local flaps
Rhomboid or modified rhomboid
Small cheek rotation advancement flaps
Subcutaneous pedicle flaps
85. Cheek reconstruction
Zone II
Vertical or posterior cheek advancement
Facelift procedure
Subcutaneous
Deep plane
Beneath SMAS
86. Cheek reconstruction
Zone II
Cervical flaps
Can include platysma with cheek flap
Avoid deep plane
Start subcutaneous
Transect platysma 4 cm below mandibular border
87. Cheek reconstruction
Zone II
Cervicopectoral flap
Best for large defects
Medially based flap
Anterior thoracic perforators of internal mammary
88. Cheek reconstruction
Zone II
Deltopectoral flap
Medially based
Reliable
Good skin match from shoulder and upper arm
Pectoralis major flap
Latissimus dorsi flap
89. Cheek reconstruction
Zone III
Similar to zone II
Issue of buccal lining
Tongue flaps
Turnover or hinge flaps
Folded skin flaps
Free flaps
Radial forearm
TFL