Lip and Cheek Reconstruction

Drs. N. Afridi and G. Sparkes

Lip reconstruction
Lip function
Oral competence Deglutition Articulation Expression of emotion Symbol of beauty

Lip reconstruction
Anatomy
Topographic landmarks

Lip reconstruction
Anatomy
Muscles

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

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

Lip reconstruction
Approach
Evaluate
Size and location of the defect Etiology of the lesion Patient age and gender

Lip reconstruction
Surgical goals
Complete skin cover and oral lining Semblance of a vermilion Adequate stomal diameter Sensation Competent oral sphincter

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

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

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

Lip reconstruction
Vermilion reconstruction
Tongue flaps
Two stage procedures Tongue mucosa
Red with poor cosmetic match Feminizing effect in men

Unpleasant experience for patients

Lip reconstruction
Vermilion reconstruction
Vermilion muscle advancement flap
Defect less than 1/3 lower vermilion Based on axial labial artery

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

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

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

Lip reconstruction
Lower lip reconstruction
Orbicularis oris flap
Rectangular excision of lower lip lesion V-Y advancement
Bipedicled orbicularis oris

Vermilion reconstruction
Labial mucosa advancement flap

Preserves muscle integrity and nerve supply

Lip reconstruction
Lower lip reconstruction
Rectangular flaps
Lower lip rectangular flaps
Labiomental region Rotated medially

Vermilion
Bilateral buccal mucosa flaps

Lip reconstruction
Lower lip reconstruction
Step method
Horizontal component of step excisions
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

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

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

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

Lip reconstruction
Lower lip reconstruction
Abbe flap
Bilateral extraphiltral cross lip flaps

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

Lip reconstruction
Lower lip reconstruction
Estlander flap
Flap design
Full thickness Medial based flap of lateral lip Supplied by contralateral labial artery size of lower lip defect Distal edge of flap tapered to nasolabial fold

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

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

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

Lip reconstruction
Lower lip reconstruction
Karapandzic flap
Advantages
Sensation and sphincter function Preferable to Bernard Burows repair Single stage procedure and less risk of flap loss Compared to Abbe flap

Disadvantages
Microstomia Inferior aesthetic result Circumoral scarring noticeable

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

Lip reconstruction
Lower lip reconstruction

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

Lip reconstruction
Lower lip reconstruction
Bernard Burows procedure
1st described
Full thickness excision 4 triangles Two have caudal base at commissure

Lip reconstruction
Lower lip reconstruction
Bernard Burows procedure
Modifications (Webster)
Excise skin and subcutaneous tissue Leave muscle intact Base triangle in nasolabial fold Paramental triangular flaps

Lip reconstruction
Lower lip reconstruction
Bernard Burows 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

Lip reconstruction
Lower lip reconstruction
Bernard Burows 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

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Lower lip reconstruction
Dieffenbach flap
Historical interest Wide inferiorly based rectangular cheek flaps Functionally impaired lip Long cheek scars

Lip reconstruction
Lower lip reconstruction
Nasolabial flaps
Inferiorly based Pivot on the commissures Mucosa lining flaps
Everted to recreate vermilion

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

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 Burows Large (greater than 2/3) Bernard Burows Karapandzic Free flap

Lip reconstruction
Upper lip
Defects less common Unique features to consider
Nose Columella Cupids bow Philtrum

Men
Hairbearing nasolabial and cheek flaps obvious Can disguise scars in a mustache

Oral competence less significant

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

Lip reconstruction
Upper lip reconstruction
Primary closure
Most satisfactory results Lateral defects
Taper incision into nasolabial fold

Lip reconstruction
Upper lip reconstruction
Perialar crescentic skin excisions
Area excised conforms to alar margin
Skin and subcutaneous tissue only

Release of upper buccal sulcus

Lip reconstruction
Upper lip reconstruction
Nasolabial flaps
Skin and subcutaneous tissue from nasolabial fold For upper lip without vermilion defect Donor site closed primarily

Lip reconstruction
Upper lip reconstruction
Abbe flap
Lip switch from lower lip Can be combined with perialar crescentic excision flaps

Lip reconstruction
Upper lip reconstruction
Reverse Karapandzic flap
Inferiorly based Carry circumoral incision to commissure

Lip reconstruction
Upper lip reconstruction
Reverse fan flap

Lip reconstruction
Upper lip reconstruction
Reverse Estlander flap

Lip reconstruction
Upper lip reconstruction
Superiorly based lower cheek flaps

Lip reconstruction
Upper lip reconstruction
Inverted Bernard Burows flap
Upper lip defect replaced with midcheek tissue Skin and subcutaneous tissue Burows triangles excised lateral to the lower lip and alar base Orbicularis muscle not violated Vermilion reconstructed with buccal mucosa

Lip reconstruction
Upper lip reconstruction
Bilateral levator anguli oris flap
Innervated Bilateral and combined with Abbe flap
Can be used for total lip reconstruction

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)

Lip reconstruction
Upper lip reconstruction
Small defects
Primary closure Perialar crescentic skin excisions

Lip reconstruction
Upper lip reconstruction
Medium defects
Central
Primary closure with perialar crescentic skin excisions Greater than Perialar crescentic with Abbe flap Karapandzic

Lateral
Commissure not involved Abbe flap Commissure involved Estlander flap

Lip reconstruction
Upper lip reconstruction
Large defects
Adequate cheek tissue
Inverted Bernard Burows procedure Bilateral levator anguli oris combined with Abbe flap

Inadequate cheek tissue

Distant pedicle flap Free flap

Lip reconstruction
Upper lip reconstruction
Hair bearing skin
Forehead flap Scalp flap Unipedicled submandibular flap Bipedicled submental flap Temporal island scalp flap
Temporoparietal fascia flap Cutaneous island at vertex of skull Pivot point at tragus Tunneled under cheek Emerges at nasolabial fold

Lip reconstruction
Commissure reconstruction
Microstomia
Lip vermilion 1st choice
Advanced or transposed full thickness flap

Buccal mucosa
Alternative

Lip reconstruction
Commissure reconstruction
Macrostomia
Congenital macrostomia
Lateral orofacial cleft between maxillary and mandibular components 1st branchial arch Incomplete orbicularis oris ring Upper lip orbicularis Contiguous with zygomaticus Lower lip orbicularis Contiguous with risorius

Lip reconstruction
Commissure reconstruction
Macrostomia
Congenital macrostomia
Operative correction Commissure positioning Reconstruction of muscle ring Upper lip orbicularis fibers placed anterior to lower lip orbicularis

Cheek reconstruction
Introduction
Aesthetic units
Zone I
Suborbital

Zone II
Preauricular

Zone III
Buccomandibular Includes oral lining in full thickness defects

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

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

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

Cheek reconstruction
Zone I
Local flaps
Swing side plasty
Reduces size of defect Minimize flap ischemia by rounding tip Avoid narrow distal tip

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

Cheek reconstruction
Zone II
Superolateral junction of helix and cheek Medially to malar eminence Inferior to mandible Covers parotid/masseteric fascia

Cheek reconstruction
Zone II
Skin grafts
Skin laxity in zone II Common donor site Use of skin graft rare
Camouflaged easily with hair

Cheek reconstruction
Zone II
Local flaps
Rhomboid or modified rhomboid Small cheek rotation advancement flaps Subcutaneous pedicle flaps

Cheek reconstruction
Zone II
Vertical or posterior cheek advancement
Facelift procedure Subcutaneous Deep plane
Beneath SMAS

Cheek reconstruction
Zone II
Cervical flaps
Can include platysma with cheek flap
Avoid deep plane Start subcutaneous Transect platysma 4 cm below mandibular border

Cheek reconstruction
Zone II
Cervicopectoral flap
Best for large defects Medially based flap
Anterior thoracic perforators of internal mammary

Cheek reconstruction
Zone II
Deltopectoral flap
Medially based Reliable Good skin match from shoulder and upper arm

Pectoralis major flap Latissimus dorsi flap

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

Cheek reconstruction

Cheek reconstruction

Cheek reconstruction

Cheek reconstruction

Cheek reconstruction

Cheek reconstruction

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

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

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.

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

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 laterally17.