Dermatologic Aspects of Lip Reconstruction Treatment & Management
- Author: R Stan Taylor, MD; Chief Editor: Dirk M Elston, MD more...
Healing by secondary intention
Because the lips have no bony, cartilaginous, or fibrous infrastructure, significant wound contraction can cause permanent retraction of the free margin of the lip. Therefore, the surgeon must carefully choose the lesions that can have an acceptable cosmetic and functional result when they are left to granulate. As the depth and diameter of lip defects increase, so does the risk of contraction that results in cosmetic or functional deficits. Superficial defects of the vermilion, even up to 2.5 cm may heal well by secondary intention.[5, 6] This method is routinely performed after carbon dioxide laser vermilionectomy in the treatment of actinic cheilitis. Also, very superficial defects of the cutaneous lip often heal well by granulation. Defects of the lateral upper cutaneous lip adjacent to the alar-cheek junction often mend well with second-intention healing. Patients with granulating lip wounds should be closely monitored for any signs of lip-notching.
As a general rule, defects that affect less than 30% of the area of the lip can be repaired primarily. Orienting the incision in the relaxed skin tension lines minimizes the appearance of the scar. Excising all redundant tissue is important to prevent puckering of the incision; for example, with defects on the cutaneous lip, the surgeon should not hesitate to extend the Burow triangle onto the vermilion if necessary. If the defect is on the vermilion, the underlying muscle may be excised and reapproximated to prevent bulging. In addition, incorporating a Z-plasty into defects in the cutaneous lip lengthens the scar, distributes the tension, and prevents distortion of the vermilion border.
Malignant neoplasms of the vermilion that cannot be treated with Mohs micrographic surgery are often excised with a full-thickness or wedge excision. This type of excision can be performed in several ways. The most common type of full-thickness excision is the triangular or V -shaped design. In this design, the base of the triangle is on the vermilion, and the 30° apex extends onto the cutaneous lip and functions as the Burow triangle to eliminate redundant tissue. Alternatively, one can design a shield or pentagonal incision, which may prevent unnecessarily wide excision of the vermilion lip.
An additional option is adding an M-plasty onto the cutaneous portion of the excision, which decreases its total length. When lesions on the lower lip are excised, the incision should not extend beyond the mental crease, to stay in one cosmetic unit. Repair of defects on the lateral lip can cause difficulty during primary repair because the vermilion tapers laterally and therefore its width can vary when it is reapposed. This problem can be corrected in 2 ways: First, a Burow wedge can be excised from the vermilion of the medial side of the wound. The second option is to design a diagonal instead of vertical incision at the lateral portion of the vermilion to leave more vermilion lip at the vermilion-cutaneous junction.[8, 10]
For optimal cosmetic and functional results, full-thickness lip resections should be repaired in 4 layers. Small-caliber 5-0 or 6-0 sutures placed with reverse-cutting needles are preferred in this delicate area.
First, the submucosa is repaired by using a small-caliber, soft, nonirritating suture such as silk or braided polyglactin (Vicryl). The surgeon should take special care to bury the knots to prevent irregular wound contours and suture spitting. Second, the orbicularis oris is repaired by using an absorbable suture such as braided polyglactin (Vicryl), braided polyglycolic acid (Dexon), or polydioxanone (PDS). Careful and meticulous reapproximation of the orbicularis oris is necessary to maintain competence of the oral sphincter. Third, the vermilion-cutaneous border should be realigned with an epidermal vertical mattress suture. Proper and exact restoration of this border is crucial for a good aesthetic outcome. Next, the dermis and subcutaneous tissue of the cutaneous lip is closed with absorbable sutures. Fourth, the surgeon closes the epidermis with a monofilament suture, taking great care to maximally evert the wound edges to prevent a depressed and noticeable scar.
Advancement flaps are commonly used to repair defects that involve 30-60% of the lip. Although many types of advancement flaps exist, those on the lip have a common feature of mobilizing tissue from the lateral lip and from the cheek to minimize distortion of the vermilion border. Another advantage of advancement flaps on the lip is the preservation of the normal directional growth of facial hairs. In a retrospective review of upper lip reconstruction, the advancement flap was the most commonly used flap.
Unilateral advancement flap
Unilateral advancement flaps are useful in repairing defects of the upper cutaneous lip that are just lateral to the philtrum. Incision lines can be hidden along either the vermilion border in more inferior defects or along the nasal sill and alar groove in more superior defects. The surgeon must be careful to obtain maximum motion from the lateral part of the lip and cheek with minimum motion from the philtrum to prevent distortion of the flap. The Burow wedge advancement flap is the most useful unilateral advancement flap because it requires fewer incisions than the traditional unilateral advancement flap. For cosmetic reasons, the incision should not extend onto the cheek, but rather, all of the incisions should be within the cosmetic unit of the lip.
In practice, the vast majority of unilateral advancement flaps consist of only cutaneous tissue, as they are only repairing cutaneous defects. However, a myocutaneous advancement flap may be used to close large lateral upper lip defects. This flap requires 2 Burow triangles: 1 at the alar groove and 1 along the lower melolabial fold lateral to the oral commissure. The flap is incised full-thickness from the lateral portion of the defect to the lateral melolabial fold and moved medially into place.
Bilateral advancement flap
Bilateral advancement flaps are commonly used to repair medial lip defects. This design allows the surgeon to recruit tissue from both sides of the wound, facilitating preservation of normal lip contours. Incisions can be hidden along the nasal sill, vermilion border, or mental crease. Dog-ear repairs can be hidden in the alar crease, vermilion lip, or nasolabial groove. The A-to-T design is useful for small defects of the cutaneous or vermilion lip, whereas standard bilateral advancement flaps are more appropriate for medium-sized defects of the lip.
One bilateral advancement flap, the split orbicularis myomucosal flap, may be used to repair large defects of the lower lip with a relatively low risk of functional impairment or microstomia. The authors report the ability to reconstruct from 50-80% of the lower lip in one stage with this procedure. In this flap, incisions are made at the vermilion border through the muscle and mucosa to the commissures, making these flaps laterally based. The flaps are sutured in place, ensuring complete and meticulous reattachment of the muscle. Any concurrent cutaneous defect is repaired with traditional techniques.
Crescentic perialar advancement flap
The crescentic perialar advancement flap was developed by Webster and involves the excision of a crescent-shaped area of the skin at the alar-cheek junction. This technique facilitates the advancement of the lip and cheek while hiding the incision in the alar crease. Both unilateral and bilateral advancement flaps may benefit from this variation. The bilateral perialar cresentic advancement flap can be used to repair small- to medium-sized defects of the central upper lip, with excellent cosmetic result. All incision lines except the vertical incision on the upper lip are hidden in the cosmetic boundaries of the nasal sill or alar groove.
Island pedicle advancement flap
The island pedicle advancement flap is commonly used for medium-sized defects in the upper lip that are near the alar-cheek junction. Incisions are made along the nasolabial fold and along a line from the inferior aspect of the defect to a common point on the more inferior nasolabial fold. The triangular flap is undermined on its edges, but the central portion is left intact and acts as a vascular pedicle. Then, the flap is advanced medially and sutured in place.
The myocutaneous island pedicle "sling" flap is also very useful in repairing defects of the philtrum. The flap is designed vertically along the philtral crests with the apex of the flap pointing toward the nasal sill; this design allows for recapitulation of the philtral columns in the repair. Another advantage to this design is that it maintains the pattern of hair growth in male patients.
Compared with the other advancement flaps, this flap has a stronger tendency to form a trap-door or pin-cushioning deformity, which may be problematic. Superficial undermining on all sides of the wound incisions may decrease the likelihood of pin cushioning
Inferiorly based rotation flaps are commonly used to repair lateral defects in the upper cutaneous lip. Thus, the incision and arc of rotation is along the nasolabial groove, which camouflages the scar. If necessary, a standing cone on the superior portion of the flap is excised along the relaxed skin tension lines of the lip. The standing cone on the inferior portion of the nasolabial groove can often be eradicated by making a back-cut. The back-cut allows for greater mobility, and it allows the surgeon to cheat out the redundant tissue. Caution must be used to prevent upward distortion of the oral commissure when this type of flap is used in large defects.
For small-to-medium defects of the central vermillion lip, bilateral rotation flaps can offer an excellent cosmetic result.[17, 18] The incisions for such flaps are made along the vermillion border, with a standing-cone repair taken along the inner vermillion and buccal mucosal lip.
An O-to-Z bilateral rotation flap design can be used in defects in the lower cutaneous lip. Incisions are made along the vermilion border and mental crease. The 2 horizontal incisions are less noticeable than others, and the main scar that remains is a diagonal scar on the lower lip.
The Karapandzic flap is often used to repair large full-thickness defects of the lip.[19, 20] This flap is designed to include the orbicularis oris, which is dissected from the surrounding muscles and includes intact neural and vascular structures. This flap is most commonly used in lower lip defects. The incision is made along the mental crease and bilateral nasolabial grooves. Then, the lateral flaps are rotated medially and meet in the midline or near midline, resulting in a smaller oral aperture. The main advantage of this flap is the preservation of the neurovascular bundle, which enables the surgeon to restore the normal sphincter function of the lips that can be lost in large defects.
Transposition flaps are most frequently used to repair medium-sized defects on the lateral upper cutaneous lip. Like advancement flaps and rotation flaps, transposition flaps involve the use of cheek tissue to fill the defect. However, transposition flaps are designed to move over stationary tissue, altering the tension forces. In designing these flaps, the surgeon should attempt to hide all of the incisions in creases, natural shadows, or relaxed skin-tension lines.
Melolabial transposition flaps
These flaps can be designed with either a superior base or an inferior base, depending on the location of the defect. Superiorly based flaps are useful in replacing tissue in the superior and medial upper cutaneous lip. In contrast, inferiorly based flaps can be designed for more lateral defects of the upper cutaneous lip. Although both designs of the melolabial transposition flap may blunt the melolabial sulcus, the superiorly based flaps generally cause more significant deformity, and hence, they are less favored.
Another disadvantage of this type of flap is the pin-cushioning or trap-door deformity of the flap. The risk can be lessened with wide undermining of the defect and by paying special attention to everting the wound edges.
Full-thickness transposition flaps
Full-thickness defects of one third to two thirds of either lip are often repaired by moving pedicled flaps from one lip to the opposite one; hence, they are sometimes called lip-switch flaps. These flaps transpose both vermilion lip and cutaneous lip, and the pedicle of the flap contains the labial artery. These flaps are advantageous because they restore the mucosa and muscle, and they match the skin to the defect[23, 24]
Two primary designs exist. The Abbe flap is used for more medially based defects of the lip. This flap is created in a 2-stage procedure in which a full-thickness fingerlike flap of tissue is excised from the normal lip and turned 180° to fill the defect on the opposite lip. Then, 10 days to 3 weeks after the initial procedure, the pedicle is divided. The Estlander flap is used for lateral defects of the lip, which involve the oral commissure. Unlike the Abbe flap, the Estlander flap is created in a 1-stage procedure because the flap is inverted and placed wholly in the lateral lip defect.
In some cases, a combination of procedures is used for the reconstruction process. One combination used frequently is a flap plus a graft. Flaps are used to restore bulk and muscle, while mucosal grafts, taken from the buccal mucosa or mucosal lip, are used to restore the appearance of the vermilion lip.
For defects of the lateral upper cutaneous lip, a combination of a medially based advancement flap with an island pedicle flap can offer excellent cosmetic results. The advancement flap is incised at the nasal sill and moved laterally to fill half or more of the defect, and the remainder of the defect is repaired with an island pedicle moved superiorly along the melolabial fold.
Another combination procedure involves the use of an island pedicle advancement flap plus a mucosal transposition flap. This combination may be used for large (40%) defects of the upper lip. The island pedicle flap, taken from the upper cutaneous lip, restores the oral sphincter. The authors then describe a transposition flap taken through the contralateral mucosal lip, which is used to restore the mucosa of the defect. The secondary defect is closed primarily. This combination closure is advantageous because it allows for the entire defect to be closed in one stage.
Full-thickness skin grafts are occasionally used to repair defects of the lip, but they are not commonly a first choice. The color and texture of the lip is difficult to match, and grafts often appear more patchlike on the lip than on other areas of the face. Also, because immobilizing the lip is impossible, the likelihood of graft failure increases. Like some transposition flaps, full-thickness skin grafts may be associated with a pin-cushioning effect when used on the cutaneous lip. However, full-thickness skin grafts are sometimes an option, and they are reportedly useful in repairing defects of the philtrum. In addition, mucosal grafts may be used to restore the appearance of the vermilion lip.
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One of the most crucial factors in lip reconstruction is correct realignment of the vermilion border. Thus, carefully and precisely marking the cutaneous-vermilion junction is necessary prior to local anesthetic infiltration. This marking can be accomplished by using either a gentian violet marking pen or sutures placed at the vermilion border. Another helpful preparative step is to mark the relaxed skin tension lines and to outline the relevant cosmetic units while the patient is sitting and prior to the administration of the anesthetic.
Beard hairs, if present, should be trimmed prior to the procedure to decrease the likelihood of wound infection and to prevent interference with suture placement. The placement of dental rolls in the gingivobuccal sulcus prior to surgery everts the lip and facilitates visualization of the vermilion and mucosal lip. In addition, the use of a chalazion clamp is often helpful in stabilizing the lip and for hemostasis.
In addition to routine postoperative care, patients who have undergone lip reconstruction need specific instructions for care during the first 48-72 hours after surgery. The patients should minimize talking, facial expressions, and excessive mouth movements.
Patients should be instructed to consume only liquids and soft foods for 2-4 days after surgery. Also, if possible, patients should be advised to avoid the use of straws for at least 1 week after surgery, because unnecessary motion of the perioral muscles can disturb the repair. Patients also should brush their teeth gingerly.
Reconstruction of the lip predisposes the patient to a host of complications, largely because of the frequent motion of this area in daily life. This mobility and the inherently rich vascularity of the lip create a special predisposition for bleeding and hematoma development. Vigilant intraoperative hemostasis is of critical importance.
Localizing and ligating the labial arteries prior to their incision greatly minimizes the risk of perioperative hemorrhage. In addition, because of the close and sometimes immediate proximity of lip defects to the oral cavity, the lip has an obviously increased risk of infection. Therefore, the administration of antibiotics is indicated after lip surgery.
Another consequence of the frequent motion of the lip is scar depression. To minimize this problem, the surgeon should aggressively evert and temporarily hyperevert the wound edges with subcutaneous sutures and epidermal vertical mattress sutures. Another common complication of lip surgery is hypertrophic scar formation, which should be detected early and treated with intralesional corticosteroids. In addition, permanent anesthesia due to the damage of the sensory nerves does occur, and patients should be warned of this risk prior to surgery.
As mentioned above, some flaps can be complicated by the pin-cushioning phenomenon even when the aforementioned preventative measures are taken. The surgeon can use intralesional corticosteroids to improve their appearance, and, if necessary, surgical revision can be performed.
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