Lip Reconstruction Procedures Workup

  • Author: Ali Sajjadian, MD, FACS; Chief Editor: Deepak Narayan, MD, FRCS   more...
 
Updated: Nov 20, 2011
 

Laboratory Studies

Beyond standard anesthetic screening, no other laboratory studies are key to reconstruction. The only other relevant laboratories studies would be related to the underlying condition producing the lip loss defect or associated patient conditions.

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Imaging Studies

Imaging studies are rarely of use in lip reconstruction, as the surface and neuromuscular anatomy is directly accessible for evaluation. An arteriogram of the facial artery branches to the lips may be helpful in circumstances where trauma or resection has altered the vascular anatomy. This may also be useful in imaging vascular malformations involving the lips.

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Histologic Findings

The relevant histologic findings address the oncologic issues of tumor resections and confirmation of margins. These are discussed in eMedicine articles Skin Cancer - Squamous Cell Carcinoma and Cancers of the Oral Mucosa.

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Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Ali Sajjadian, MD, FACS  Private Practice, Newport Beach, California; Former Assistant Professor of Plastic Surgery, Former Director of Aesthetic Plastic Surgery Satellite Centers, University of Pittsburgh Medical Center

Ali Sajjadian, MD, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, American Society of Plastic Surgeons, American Society of Plastic Surgeons, California Medical Association, Northeastern Society of Plastic Surgeons, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Nima Naghshineh, MD, MSc  University of Pittsburgh School of Medicine

Disclosure: Nothing to disclose.

Rana Rofagha Sajjadian, MD  Clinical Instructor, Department of Dermatology, University of Irvine, California; Division of Mohs Surgery, Department of Dermatology, Southern California Permanente Medical Group

Rana Rofagha Sajjadian, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, and American Society for MOHS Surgery

Disclosure: Nothing to disclose.

Wayne Karl Stadelmann, MD  Stadelmann Plastic Surgery, PC

Wayne Karl Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Plastic Surgeons, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Gordon R Tobin, MD, FACS  Professor of Surgery, Director Emeritus, Executive Faculty, Division of Plastic and Reconstructive Surgery, Associate in Oncology, James Graham Brown Cancer Center, University of Louisville School of Medicine

Gordon R Tobin, MD, FACS is a member of the following medical societies: American Association for the Advancement of Science, American Association of Clinical Anatomists, American Association of Plastic Surgeons, American Medical Association, American Society of Plastic and Reconstructive Surgery, Arizona Medical Association, Association of VA Surgeons, Kentucky Medical Association, Pan American Medical Association, Phi Beta Kappa, Plastic Surgery Research Council, Sigma Xi, Society of University Surgeons, and Southeastern Society of Plastic and Reconstructive Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Lawrence Ketch, MD, FAAP, FACS  Head, Program Director, Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Colorado Health Sciences Center; Chief, Pediatric Plastic, The Children's Hospital of Denver

Lawrence Ketch, MD, FAAP, FACS is a member of the following medical societies: American Academy of Pediatrics, American Association for Hand Surgery, American Association of Plastic Surgeons, American Burn Association, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Society for Surgery of the Hand, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Plastic Surgery Research Council

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

R Edward Newsome†, MD  Former Program Director and Chief of Plastic Surgery, Henderson Chair in Surgery, Former Assistant Dean for Graduate Medical Education, Tulane University School of Medicine

R Edward Newsome†, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Plastic and Reconstructive Surgery, American Society of Plastic Surgeons, and Louisiana State Medical Society

Disclosure: Nothing to disclose.

Nicolas (Nick) G Slenkovich, MD  Director, Colorado Plastic Surgery Center

Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Deepak Narayan, MD, FRCS  Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center

Deepak Narayan, MD, FRCS is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Indian Medical Association, Plastic Surgery Research Council, Royal College of Surgeons of Edinburgh, and Royal College of Surgeons of England

Disclosure: Nothing to disclose.

References

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Aesthetic units of the face.
Superficial anatomy of the lower face.
Muscular anatomy of the face.
Cutaneous innervation of the face and facial nerve distribution.
Blood supply and lymphatic drainage of the face.
Wedge excision and primary closure.
Abbe flap technique.
Estlander flap technique.
Gillies fan flap technique.
Karapandzic flap technique.
Bernard-Burow flap technique.
A and B. Central upper lip defect reconstruction with the perialar skin crescent method that retains motor and sensory innervation to the advanced upper lip lateral elements and uses an Abbe flap for philtral reconstruction. Used with permission of WB Saunders Company.
Bilateral depressor anguli oris total lower lip reconstruction. A. Flap design shows the relationships of the incision, muscle, motor nerve (VII), and sensory nerve (V). B. Flap transposition reorients the depressor anguli oris to restore the lower lip oral sphincter. Vermilion is created by mucosal advancement. C. Flap insert and direct donor defect closure complete the reconstruction.
von Bruns nasolabial flap technique.
A and B. Lip reconstruction. Bilateral orbicularis oris composite flap reconstruction of a large central upper defect. The aesthetic qualities of this reconstruction are enhanced by an Abbe flap philtral reconstruction.
A bilateral levator anguli oris flap total upper lip reconstruction. A. Flap design shows the relationship of the incisions, muscle, and lower lip Abbe flap for philtral reconstruction. B. Flap transposition reorients the muscles to become the upper lip sphincter. Motor (buccal) and sensory (infraorbital) nerves entering the lateral flap border are carefully preserved in dissection and transfer. Mucosal advancement restores vermilion and an Abbe flap restores the philtrum. C. Donor defect is closed directly and the Abbe flap pedicle is divided at 2 weeks.
Left: A patient with midline and left lateral lesions each occupying less than one third of the lower lip. Right: Wedge excision of the lesions.
Left: W-closure with bilateral advancement flaps of midline defect along with mucosal advancement flap of left lateral defect. Right: Postoperative follow-up showing excellent aesthetic results.
Left: Excision of large lesion occupying greater than 85% of the upper lip. Center: Selection of regional temporal interpolated flap based on the temporal artery. In this case, significant involvement of the cheek as well as compromised vasculature secondary to Mohs surgery did not allow for an advancement flap such as the Karapandzic flap. Right: Postoperative follow-up showing good aesthetic reconstruction of the ala of the nose, upper and lateral lip, and cheek.
Left: A patient with a midline upper lip lesion. Right: Reconstruction of medium to large upper lip defect with a modified unilateral Karapandzic flap. The nasal defect was closed with an internal mucosal advancement flap, a cartilage graft from concha of the ear, and a paramedian forehead flap for external reconstruction.
Left: Mohs surgical excision of the upper lip lesion affecting the left ala of the nose and leaving a defect occupying approximately 50-60% of the upper lip. Right: Postoperative follow-up showing good aesthetic reconstruction of the left ala of the nose and upper lip.
Left: Superficial lower lip cancer. Center: Resection of cancer with margins including the entire segment of the dry and major segment of the wet portion of the lower lip. Right: Vermilion advancement flap after dissection intraorally to the gingivobuccal sulcus.
Left: Small lower left lip lesion. Center: Excision and primary closure. Right: Postoperative results.
Left: Full-thickness left upper lip defect. Center: Medial advancement of the upper lip along subunits lines leading to the final scar being placed along the philtral column of the upper lip. Right: Postoperative results.
Left: Near midline small upper lip defect. Right: Burow wedge excision with primary closure (A-to-T flap).
Upper left: Left upper lip defect (< 1/3). Upper right: Medial advancement of the upper lip along subunits lines, leading to the final scar being placed along the philtral column of the upper lip. Lower left: Early postoperative follow-up. Lower right: Late postoperative follow-up.
Left: Right upper lip defect (~1/3). Right: Primary closure of defect.
Table 1. Muscles of Facial Expression
MuscleOriginInsertionNerveAction
Elevators
Levator labii superiorisAbove and medial to the infraorbital foramenSkin and muscle of upper lipBuccal branch of facial nerve (VII)Elevates and everts upper lip
Levator labii superioris alaeque nasiFrontal process of maxillaSkin of lateral nostril and upper lipBuccal branch of facial nerve (VII)Elevates upper lip and dilates nostril
Levator anguli orisCanine fossa of maxilla below infraorbital foramenOuter end of upper lip and modiolusBuccal branch of facial nerve (VII)Elevates angle of mouth medially
Zygomaticus majorZygomatic archModiolus at angle of the mouthBuccal branch of facial nerve (VII)Elevates and draws laterally the angle of the mouth
Zygomaticus minorLateral infraorbital marginLateral skin and muscle of upper lipBuccal branch of facial nerve (VII)Elevates and everts upper lip
Depressors
Depressor labii inferiorisMandible below mental foramen along oblique lineOrbicularis oris and skin of lower lipMandibular branch of facial nerve (VII)Depresses and laterally draws lower lip
Depressor anguli orisOblique line of mandibleModiolus at angle of the mouthMandibular branch of facial nerve (VII)Depresses and laterally draws angle of the mouth
Miscellaneous
RisoriusFascia over masseterModiolus and skin at angle of the mouthBuccal branch of facial nerve (VII)Retracts angle of the mouth
Buccinator……Buccal branch of facial nerve (VII)…
MentalisIncisive fossa do mandibleSkin of chinMandibular branch of facial nerve (VII)Elevates and protrudes lower lip
Table 2. Partial-Thickness Defect Repair
Defect TypeLower Lip DefectsUpper Lip Defects
1-2 cm>2 cm
Mucosal-Primary closure



-Secondary intention



-Vermilionectomy/laser ablation



-Primary closure



-Secondary closure



-Vermilionectomy/laser ablation



Inferiorly based nasolabial flap
Midline-Bilateral advancement flap



-Adjacent labiomental crease A-to-T flap



Philtrum only:



-Secondary intention



-Full-thickness skin graft



Adjacent to philtrum:



-Perialar crescentic advancement flap



Lateral-Advancement flap



-Rotation flap



-Transposition flap



In order of increasing laterality of defect:



-Inferiorly based nasolabial flap



-Laterally based rotation flap



-Primary closure



Adjacent vermilionA-to-T flapA-to-T flap
Table 3. Full-Thickness Defect Repair
Defect TypeLower Lip DefectsUpper Lip Defects
Defect SizeDefect Size
< 30%30-60%>60%< 30%30-60%>60%
MidlinePrimary closure-Bilateral advancement flap



-Karapandzic flap



-Karapandzic flap



-Bernard-Burow flap



-Gillies fan flap



-Regional flap



-Free flap



Primary closure-Perialar crescentic advancement flap and Abbe flap



-Karapandzic flap and Abbe flap



-Nasolabial flap and Abbe flap



-Karapandzic flap and Abbe flap



-Regional flap



-Free flap



Near oral commissurePrimary closure-Abbe flap



-Depressor anguli oris flap



...Primary closure-Unilateral perialar crescentic advancement flap



-Abbe flap



...
Involving oral commissurePrimary closureEstlander flap...Primary closureEstlander flap...
Philtrum only.........-Primary closure



-Abbe flap



......
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