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.

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.

Histologic Findings

The relevant histologic findings address the oncologic issues of tumor resections and confirmation of margins. These are discussed in Medscape Reference articles Head and Neck Cutaneous Squamous Cell Carcinoma and Cancers of the Oral Mucosa.

Treatment & Management

Neligan PC. Strategies in lip reconstruction. Clin Plast Surg. 2009 Jul. 36(3):477-85. [QxMD MEDLINE Link].
Krunic AL, Weitzul S, Taylor RS. Advanced reconstructive techniques for the lip and perioral area. Dermatol Clin. 2005 Jan. 23(1):43-53, v-vi. [QxMD MEDLINE Link].
Odell MJ, Varvares MA. Microvascular reconstruction of major lip defects. Facial Plast Surg Clin North Am. 2009 May. 17(2):203-9. [QxMD MEDLINE Link].
Dieffenbach JF. Die operative chirurgie. Leipzig Brockhaus: 1845. Vol 1: 423.
Dieffenbach JF. Chirurgische Erfahrungen, bensonders uber die Wiederherstellung Zerstoerter Theile des Menschlichen Koerpers nach Neuen Methoden. Berlin: TCF Enslin; 1829. 34.
Sabattini P. Cenno storico dell-origine e progresso della rinoplastica e cheiloplastica seguito dalla descrizione di queste operazioni sopra un solo individuo. Bologna: Balla Arti; 1838.
Abbe R. A new plastic operation for the relief of deformity due to double harelip. Med Rec. 1898. 53:447.
Estlander JA. Methode d’autoplastie de la joue ou d’une levre par un lambeau emprunte a l’autre levre. Rev Mens Med Chir. 1877. 1:344.
Mazzola RF, Lupo G. Evolving concepts in lip reconstruction. Clin Plast Surg. 1984 Oct. 11(4):583-617. [QxMD MEDLINE Link].
Bernard C. Cancer de la levre inferieure opera par un procede nouveau. Bull Mem Soc Chir Paris. 1853. 3:357.
von Burow CA. Beschreibung einer neuen Transplantations-Methode (Methode der seitlichen Dreiecke) zum Wiedersatz verlorengenangener Teile des Gesichts. Berlin, Nauck; 1855.
Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg. 1974 Jan. 27(1):93-7. [QxMD MEDLINE Link].
Ishii LE, Byrne PJ. Lip reconstruction. Facial Plast Surg Clin North Am. 2009 Aug. 17(3):445-53. [QxMD MEDLINE Link].
Bektas G, Cinpolat A, Biçici P, Seyhan T, Coskunfirat OK. Reconstruction of lateral lower lip defects with transverse lip advancement flap. J Craniofac Surg. 2013 May. 24(3):984-6. [QxMD MEDLINE Link].
Tan O, Kuduban SD, Algan S, Cinal H, Barin EZ. Total Lower Lip Reconstruction Using Free Neurotendinofasciocutaneous Anterolateral Thigh Composite Flap: A Case Report. J Reconstr Microsurg. 2013 May 13. [QxMD MEDLINE Link].
Powar RS, Vijaya Kumar N, Das R. A new tailored technique of vermilion repair in unilateral cleft lip. J Plast Reconstr Aesthet Surg. 2013 Jul. 66(7):896-9. [QxMD MEDLINE Link].
Jacono AA, Bassiri M, Talei B. Bilateral Transposition Lip Flaps: A Novel Single-Stage Reconstruction of Central Upper Lip Defects Involving Cupid's Bow. JAMA Facial Plast Surg. 2015 Mar 12. [QxMD MEDLINE Link].
Ouhayoun L, Madar Y, Chatel H, Benoilid M, Tresallet C, Quilichini J. Upper lateral lip flap for the coverage of large superficial labial defect. Ann Chir Plast Esthet. 2020 Jul 9. [QxMD MEDLINE Link].
Gillies HD. Plastic Surgery of the Face. London: Oxford University Press; 1980.
Teemul TA, Telfer A, Singh RP, Telfer MR. The versatility of the Karapandzic flap: a review of 65 cases with patient-reported outcomes. J Craniomaxillofac Surg. 2017 Feb. 45 (2):325-9. [QxMD MEDLINE Link].
Tobin GR. Lower lip and oral sphincter reconstruction with innervated depressor anguli oris flaps. Presented at: the 62nd Annual Meeting of the American Association of Plastic Surgeons. Colorado Springs, Colo; 1983.
Mantsopoulos K, Iro H, Constantinidis J. Reconstruction of the Oral Commissure With the Zisser Flap. J Oral Maxillofac Surg. 2019 Feb 19. [QxMD MEDLINE Link].
Thomson HG. Commissure reconstruction: overview. Strauch B, Vasconez LO, Hall-Findlay EJ, Lee BT, eds. Grabb's Encyclopedia of Flaps: Head and Neck. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009. vol 1: 517.
Fujimori R. "Gate flap" for the total reconstruction of the lower lip. Br J Plast Surg. 1980 Jul. 33(3):340-5. [QxMD MEDLINE Link].
Meyer R, Abul Failat AS. New concepts in lower lip reconstruction. Head Neck Surg. 1982 Jan-Feb. 4(3):240-5. [QxMD MEDLINE Link].
Sadove RC, Luce EA, McGrath PC. Reconstruction of the lower lip and chin with the composite radial forearm-palmaris longus free flap. Plast Reconstr Surg. 1991 Aug. 88(2):209-14. [QxMD MEDLINE Link].
Schuller M, Gosau M, Muller S, et al. Long-term outcome and subjective quality of life after surgical treatment of lower lip cancer. Clin Oral Investig. 2014 Sep 27. [QxMD MEDLINE Link].

Media Gallery

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.

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Table 1. Muscles of Facial Expression

Muscle	Origin	Insertion	Nerve	Action
Elevators
Levator labii superioris	Above and medial to the infraorbital foramen	Skin and muscle of upper lip	Buccal branch of facial nerve (VII)	Elevates and everts upper lip
Levator labii superioris alaeque nasi	Frontal process of maxilla	Skin of lateral nostril and upper lip	Buccal branch of facial nerve (VII)	Elevates upper lip and dilates nostril
Levator anguli oris	Canine fossa of maxilla below infraorbital foramen	Outer end of upper lip and modiolus	Buccal branch of facial nerve (VII)	Elevates angle of mouth medially
Zygomaticus major	Zygomatic arch	Modiolus at angle of the mouth	Buccal branch of facial nerve (VII)	Elevates and draws laterally the angle of the mouth
Zygomaticus minor	Lateral infraorbital margin	Lateral skin and muscle of upper lip	Buccal branch of facial nerve (VII)	Elevates and everts upper lip
Depressors
Depressor labii inferioris	Mandible below mental foramen along oblique line	Orbicularis oris and skin of lower lip	Mandibular branch of facial nerve (VII)	Depresses and laterally draws lower lip
Depressor anguli oris	Oblique line of mandible	Modiolus at angle of the mouth	Mandibular branch of facial nerve (VII)	Depresses and laterally draws angle of the mouth
Miscellaneous
Risorius	Fascia over masseter	Modiolus and skin at angle of the mouth	Buccal branch of facial nerve (VII)	Retracts angle of the mouth
Buccinator	…	…	Buccal branch of facial nerve (VII)	…
Mentalis	Incisive fossa do mandible	Skin of chin	Mandibular branch of facial nerve (VII)	Elevates and protrudes lower lip

Table 2. Partial-Thickness Defect Repair

Defect Type	Lower Lip Defects	Upper Lip Defects
Defect Type	Lower 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 vermilion	A-to-T flap	A-to-T flap

Table 3. Full-Thickness Defect Repair

Defect Type	Lower Lip Defects			Upper Lip Defects
	Defect Size			Defect Size
	< 30%	30-60%	>60%	< 30%	30-60%	>60%
Midline	Primary 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 commissure	Primary closure	-Abbe flap -Depressor anguli oris flap	...	Primary closure	-Unilateral perialar crescentic advancement flap -Abbe flap	...
Involving oral commissure	Primary closure	Estlander flap	...	Primary closure	Estlander flap	...
Philtrum only	...	...	...	-Primary closure -Abbe flap	...	...

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Lip Reconstruction Procedures Workup

Laboratory Studies

Imaging Studies

Histologic Findings

References

Tables

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