Lip Reconstruction Procedures Treatment & Management

No medical therapy exists for lip loss. Dental prosthetics are ineffective for lip restoration. However, they do have substantial value in replacing loss of maxillary or mandibular bony support for the lips in certain circumstances when these underlying structures are missing.

Preoperative considerations include determination of whether the conditions are appropriate for reconstruction, flap design along with appropriate markings, oral hygiene, preparation of surgical area, and communication of possible outcomes with the patient.

Oncologic resection is a major cause of lip defects. Hence, prior to reconstruction, pathology results on complete resection of tumor and clear surgical margins must be confirmed. When trauma is the etiology or accompanies the defect, it is imperative to allow recovery while keeping in mind the possibility of distortion of local anatomy and vascular supply.

Flap design includes assessing the size and shape of the defect and the availability of replacement tissue. ^{[13, 14, 15]} As such, the location of the donor sight may vary (from local to distant flaps) based on defect size and whether the surrounding anatomy is preserved, since trauma is often extensive and may not be localized. Prior to administration of anesthetics, mark the cutaneous-vermilion border to aid in realignment and note relevant cosmetic landmarks such as folds, shadows, and tension lines. ^[16] This is imperative, as injection of local anesthetics distorts the normal anatomy. Oral hygiene should be optimized and hairs trimmed to decrease the chance of infection.

Since the obstacles of reconstruction may not be apparent prior to surgery, communicate to the patient or family the variability in functional and aesthetics outcomes. Doing so instills reasonable expectations that may make the postoperative period less difficult for the patient or the family.

Defect repair

Different defects require different repair techniques. Alternatively, different techniques may be appropriate for a particular defect. Tables 2 and 3 outline defect types, sizes, and locations and the appropriate techniques that may be used in repairing those defects. Details concerning specific techniques are discussed in the next section.

Table 2. Partial-Thickness Defect Repair (Open Table in a new window)

 

Table 3. Full-Thickness Defect Repair (Open Table in a new window)

 

A retrospective study by Jacono et al indicated that bilateral transposition flaps can be used in a single-stage procedure to reconstruct the Cupid’s bow and philtrum. The study involved seven patients who underwent upper lip reconstruction after Mohs surgery, with no secondary defects remaining after the single-stage reconstruction. ^[17]

A retrospective study by Ouhayoun et al indicated that use of an upper lateral lip rotation flap is an aesthetically effective means of addressing large superficial defects of the upper lip. The investigators reported that such flaps can repair lateral upper lip defects of up to 3 cm in size, allowing scars to be concealed in natural folds. Moreover, the flaps permit coverage of lip defects with lip tissue and, in men, restoration of upper lip pilosity. All patients in the study experienced complete healing by postoperative day 15, with no flap necrosis or nasal or lip distortion found. ^[18]

A number of repair techniques are described below.

Primary closure

Primary repair involves reapproximation of defect edges and is generally reserved for smaller defects and involves consideration of several factors (see images below). Closure should occur along relaxed skin tension lines or, when possible, along folds (eg, nasolabial). Typically, tissue is at a premium in defect reconstruction; however, if necessary, excessive tissue must be excised and the vermilion border must be realigned exactly to ensure appropriate aesthetic outcome. This is most often performed using a Burow wedge or V excision based on the vermilion with a 30-degree apex (or an A-to-T flap). This is also where preoperative markings greatly aid in repair. Repair options may include M-plasty or Z-plasty to release tension that would distort the shape of the mouth or the vermilion border.

Closure is generally done in 3 or 4 layers, making sure the knots are buried or embedded to prevent surface irregularities, vermilion border and muscle approximation are precise, and wound edges are everted to prevent noticeable scar formation.

Cross-lip flap

Cross-lip flap reconstruction allows for repair of fairly large defects with tissue that is similar to the excised tissue. It allows for distribution of upper and lower lip discrepancy that would occur with primary closure. The technique allows for minimal disruption of muscle orientation in both donor and recipient sites. Though denervation of the orbicularis oris may occur, the orbicularis muscle reinnervates with adequate functioning with one-year postoperative electromyography. The disadvantage of this technique is that it reduces the oral circumference; microstomia becomes an important issue with increasingly large defects.

Abbe flap

Used for repair of defects near the oral commissure, the flap is planned about one-half the size of defect (see image below). One aspect of the flap is incised full-thickness, while the inferiormost aspect of the flap is only excised three-fourths full-thickness to create a pedicle that preserves the vascular supply (labial artery). Three-layer closure is performed, with emphasis on accurate alignment of the vermilion border. At 3 weeks, the pedicle is separated and the mucosa is repaired or allowed to heal as necessary.

Estlander flap

As the first step in commissure reconstruction, the Estlander flap allows for repair of defects at the oral commissures. With a base larger than that of the Abbe flap, the full-thickness incision is placed along the nasolabial fold (see image below). Upon realignment of the vermilion border, the mucosa may need to be advanced to match the thickness of the recipient site. A commissureplasty is then performed at 3 months to restore the normal appearance of the angle of the mouth. A modification to the Estlander flap is the reverse Abbe flap, which avoids revision commissureplasty by transposing instead of rotating the flap.

Gillies fan flap

An extension of the Estlander flap, the Gillies flap allows for subtotal or total lip reconstruction. This is accomplished through bilaterally expanding the tissue used to include areas lateral to the commissures. The flap is rotated to create new commissures while advanced medially to fill the defect (see image below). Though this method leads to denervation, it does preserve partial continuity of the musculature, which was shown by Gillies to regain eventual partial function through neurotization. ^[19] However, sensory loss and vermilion deficiency continue to be disadvantages to this technique. Later, the Karapandzic flap improved on this technique by maintaining the neurovascular structures.

Karapandzic flap

Used primarily for midline medium-sized defects, the Karapandzic flap has also been used in total lower lip defects (see images below). Since this is an innervated flap with neurovascular structures intact, this method of repair allows for immediate muscle use as compared to cross-lip flap and fan flap techniques. The method involves the use of tissue surrounding the defect. Three-quarter–thickness incisions are made, and, with separation of muscle fibers allowing for advancement of the flap, the tissue around the defect is reapproximated. Perioral incisions extending along the nasolabial fold ease the advancement of the flap medially. Though a very useful technique, the drawback of this method is the considerable microstomia that may result.

A retrospective study by Teemul et al of patients who underwent Karapandzic flap reconstruction for cancer resection–associated lip defects reported low mean Patient and Observer Scar Assessment Scale scores for patients and observers. The flap was also found to permit adequate margin clearance, with no cancer recurrence or surgical revision needed in patients followed up after 1 year. ^[20]

Bernard-Burow flap

The Bernard-Burow flap allows reconstruction of larger lower lip defects using advancement of adjacent cheek tissue (see image below). The method involves transposition of triangular flaps with bases at the level of the commissures and flipping over of superior triangular flaps to reconstruct the vermilion using buccal mucosa. These earlier methods transected perioral musculature, which resulted in complete loss of muscle function.

The Webster modification of the Bernard-Burow flaps involves locating the triangular flaps along the nasolabial fold with excision only through skin and subcutaneous tissue to preserve the neuromuscular structures. The modification also calls for paramental Burow triangles that facilitate the advancement of cheek tissue. Williams introduced a combination Bernard-Burow and cross-lip flap that addresses the lip tissue discrepancy and allows for replacement of the philtral subunit in subtotal or total lip reconstruction. Though these methods allow for repair of large centrally located defects, the disadvantages include loss of motor and sensory function; however, typically, the tightness of the reconstruction may provide sufficient oral continence.

Perialar crescentic advancement flap

Essentially a modification of the Bernard-Burow flap, the perialar crescentic advancement flap alters the location of the scar so that it lies within the perialar and nasolabial folds, allowing for less distortion due to tension (see image below). The technique, used primarily for upper lip repair, involves a curvilinear incision that naturally follows the nasolabial fold and is generally 3 times larger than the diameter of the defect. It allows for musculocutaneous advancement of adjacent cheek tissue and may be combined with an Abbe flap to reconstruct central defects, as well.

Depressor anguli oris flap

First described by Tobin, this composite flap consists of muscle, skin, and buccal mucosa and maintains its motor and sensory innervation in the repair of lateral lower lip defects. ^[21] Based superiorly, the flap contains the marginal mandibular branch of the facial nerve (motor) and the mental branch of the trigeminal nerve (sensory). Bilateral flaps allow for repair of larger subtotal lower lip defects (see image below).

Zisser flap

A retrospective study by Mantsopoulos et al indicated that Zisser flap surgery, involving cheek advancement and mucosal flap repair, with the deepithelialized flap rotated into the defect, is an effective means of oral commissure reconstruction. Individuals in the study sustained commissure damage via trauma, burns, or malignant tumor resection, with oral competence and mouth opening reaching normal levels postoperatively in 12 of the study’s 13 patients. No postsurgical blunting or microstomia was found, and at 10- to 140-month follow-up, tumor recurrence was detected in none of the oncology patients. ^{[22, 23]}

Nasolabial flap

These flaps, originally inferiorly based and rotated around the commissures as described by von Bruns, allow for total lower lip reconstruction (see image below). The technique uses bilateral nasolabial tissues and rotates them inferiorly and medially to re-form a complete lower lip. As with other procedures, the buccal mucosa is later used to form the vermilion. Fujimori and Meyer later describe modifications to this technique that allow for full-thickness island flap transfer via the angular vessels. ^{[24, 25]} Nevertheless, the methods result in denervation with less than satisfactory oral sphincter function.

Regional and free flaps

When significant trauma or very large oncologic resections make the use of local tissues impossible, regional or distant flaps are necessary for lower face and lip reconstruction (see image below). Regional flaps include submandibular, anterior cervical, forehead, deltopectoral, and sternocleidomastoid musculocutaneous flaps. More recently, radial forearm free flaps employing microvascular techniques for extensive lower lip defects have been described. ^[26] Though insensate and lacking motor functionality, various steps have been described to improve oral competence. For example, the tendon of the palmaris longus may be attached to the modiolus, thereby acting as a scaffold for the newly constructed lip.

Other options described in the literature include use of the gracilis and anterolateral thigh free flaps for large defects. Though this discussion is beyond the scope of this article, osteocutaneous radial forearm, fibula, and subscapular flaps can be used to provide a rigid reconstruction when defects involve bony structures.

Other microvascular developments include replantation of traumatic amputation of the upper or lip. This method also results in a denervated flap (though neurotization has been shown) and, when selected for appropriate cases, has been shown to have excellent cosmetic results.

Vermilionectomy and laser ablation

Actinic cheilitis and squamous cell carcinoma in situ (most commonly of the lower lip; see image below) are the primary indications for vermilionectomy or laser ablation. Two or three passes using a carbon dioxide laser allows for cosmetically superior removal of confirmed lesions. When indicated, a vermilionectomy is performed using a fusiform excision in a submucosal plane.

When more fullness is desired, a posterior musculomucosal flap is advanced, and the vermilion border is reapproximated, making sure no tension exists on the incision line. If incisions must cross the vermilion border, they should do so at 90 degrees to allow for exact realignment, since even a 1-mm discrepancy along the border is noticeable at 3 feet (typical conversation distance). Again, proper marking of the vermilion-cutaneous border is critical. Possible disadvantages to the lip shave technique include loss of lip pout and inward drawing of hair, which may lead to constant irritation of mucosa.

Secondary intention

Secondary intention involves the union of 2 granulating surfaces accompanied by suppuration and delayed closure. With the lips, the risk of scar formation with wound contraction is increased; as such, lesions allowed to heal by secondary intention must be appropriately selected. Granulation can be allowed after some Mohs surgeries, superficial defects of the vermilion (eg, after carbon dioxide treatment for actinic cheilitis), and superficial defects of the cutaneous portion of the lip (especially the lateral upper cutaneous lip adjacent to the alar-cheek junction). However, the risk of distortion through wound contraction, which increases with the increasing depth or width of the wound, must be considered.

Full-thickness skin grafts

Skin grafts are not commonly used in lip repair, as the risk of graft failure is higher because of the inability to immobilize the lips. Furthermore, matching the color and texture of the skin at donor and recipient sites is difficult. In men, lack of hair on the upper lip may be quite obvious. Inability to find a good match results in an unnatural and patchy appearance. Philtral defects may even be expanded to include the entire philtrum so that a full-thickness skin graft may be used in reconstruction with good cosmetic outcomes. Donor locations can be preauricular, postauricular, supraclavicular, forehead, upper eyelid, and cervical. Less ideal donor sites include hairless groin skin, dorsum of the foot, wrist flexion crease, and elbow crease.

Postoperative care of patients who have undergone lip reconstruction involves appropriate wound care. Oral hygiene should be maintained with antiseptic mouthwash, a diluted hydrogen peroxide rinse, or both. Cutaneous suture lines should be cared for in the typical postoperative fashion by routinely cleansing with soap, hydrogen peroxide, or both, followed by the application of antibiotic ointment.

Excess tension on the repair should be avoided. This includes minimizing talking, minimizing facial expressions, and consuming only small bites of food. Initially, a liquid or soft food diet may be necessary, while those with extensive reconstructions may require placement of feeding tubes.

Sutures may be removed as early as 1 week postoperatively. Cross-lip pedicles may be separated at 3 weeks. The timing of revision or staged (eg, commissureplasty) surgeries varies based on the complexity of the reconstruction.

Perform periodic follow-up care at appropriate intervals to observe the natural return of function and to ensure that scar contracture does not distort the result. If either complication is noted, appropriate physical therapy and scar contraction treatment measures may be instituted. If the reconstruction was performed for oncologic purposes, the follow-up schedule should be tailored to detect potential recurrence.

For excellent patient education resources, visit eMedicineHealth's Cancer Center. Also, see eMedicineHealth's patient education article Cancer of the Mouth and Throat.

Early complications

Given the rich vascular supply of the lips, meticulous intraoperative hemostasis is imperative to reduce the risk of postoperative hematoma formation and hemorrhaging. Conversely, the extensive vascular supply makes flap loss or necrosis less likely. However, pedicles must be handled with care, as kinking or damage to the vascular supply could increase the risk of flap loss. This is especially critical when the vascular supply has been compromised by extensive trauma.

Infection, suture abscess, sialocele, and fistula formation can be minimized with appropriate care of suture lines, appropriate preoperative oral hygiene, perioperative prophylactic antibiotics, and careful surgical technique.

Late complications

Aesthetic and functional loss can arise from scar formation and wound contracture, which can be prevented with eversion of the wound edges with subcutaneous sutures and epidermal vertical mattress sutures. They can also be treated with release and Z-plasty. Another potential complication is hypertrophic scar formation and pincushioning. This may be treated with intralesional corticosteroid injections but may require revision surgery.

With reconstructions due to oncologic resections, tumor recurrence is a dreaded complication. Hence, negative margins on pathology must be confirmed prior to reconstruction.

Many flap techniques lead to insensate lips. This may lead to inadvertent repeated trauma to the flap and stress on the pedicle by the patient. As such, part of the preoperative and postoperative instructions to the patient should be a reminder about this possible complication or expected adverse effect.

Careful selection of techniques appropriate to the defect, in addition to observing principles of preserving and restoring motor and sensory function, has substantially improved the results of contemporary reconstructions compared to those obtained historically. The development and recognition of the innervated composite flaps also has substantially enhanced outcome as compared with historic procedures, which often cut across valuable neuromuscular structures and impaired the quality of outcome.

A study by Schüller et al indicated that following surgery for cancer of the lower lip, the Abbe and stair-step reconstruction techniques tend to offer patients a better postoperative quality of life—with regard to sensibility, paraesthesia, lip pursing, and mouth opening—than does the modified Bernard-Fries method. ^[27]

Substantial opportunity exists for future contributions to the field, particularly in the case of massive lip loss in which no perioral tissues are available for reconstruction. The techniques for achieving best functional outcome when distant tissues must be imported by pedicle or microsurgical technique are incompletely defined at present. Currently, no generally available method achieves a high-quality aesthetic and functional result in total loss of both upper and lower lips.

Partial face transplantation (including the lips) is an option that may be considered as an experimental approach to solving the problem of massive lip loss. Despite the publicity surrounding the few reported cases, numerous practical problems remain to be solved, including donor shortage and the risks of immunosuppression.