Lip Reconstruction

With any surgical reconstruction, one must take into consideration many factors that affect overall satisfaction in terms of functional and aesthetic results. The lip is no exception. Functionally, the lips serve as borders of the oral commissure, providing adequate access to the oral cavity and contributing to oral competency. Aesthetically, the lips are the focal point for verbal expression and are fundamental to the overall appearance of the face.

Lip reconstruction is not a new concept. Evidence supports that techniques used today were discussed as early as 1000 BC in the sacred texts of Susruta, India. Tagliacozzi originally popularized tissue transfer techniques in the late 16th century. Von Burow first used the technique of skin triangle excisions to facilitate flap advancement in the early 19th century. Shortly thereafter, in 1834, Dieffenbach described the first cheek advancement flap techniques. The late 19th century was a time of the popular contributions of Abbe, Sabattini, and Estlander. The last century is considered to be one of refinement of the above-mentioned principles. Techniques popularized by Karapandzic and Hari and Ohmori highlight the ability to more effectively address the largest lip defects. Karapandzic introduced the myoneurovascular pedicled advancement flap, and Harii and Ohmori performed the microvascular free tissue transfer for lip reconstructions in 1974.[1]

This article discusses principles for the reconstruction of all lip defects of traumatic and neoplastic origin. Concepts for cleft lip reconstruction are discussed in the article Cleft Lip.

Frequency

Lip carcinoma is the most common oral cavity malignancy. It is the site of almost 30% of all oral cavity malignancies.

Lip reconstruction techniques are most commonly used in neoplastic disease cases because carcinoma of the lip is the most prevalent location for oral cavity carcinomas. However, traumatic deformities comprise defects that may also require the reconstructions discussed in this article.

Lip defects can be classified according to thickness of the defect (ie, skin or mucosa only, full-thickness) and overall size of the defect. Individual patient factors, such as previous operations, underlying comorbidities, compliance, and mechanisms for the wound defect, may affect choices of reconstruction; therefore, several different options should be available for each defect. Upper and lower lip defects are best described separately. Though the choices of flaps abound, perhaps understanding the principles of a few flaps is best. Becoming familiar with the principles of a few flaps is important because the actual defect size is not often known until immediately prior to reconstruction.

The hexagonal lip aesthetic subunit can be divided into upper and lower divisions. The upper lip is further divided into 2 lateral subunits and a central philtral subunit. The inferior division is divided simply at the vermillion border. In general, entire subunits must be excised and reconstructed to conform to the aesthetic principles of scar camouflage. This system also allows for discussion of each subunit and its reconstructive possibilities.

Several algorithms have been described that match depth, size, and location of a defect with the suggested reconstruction. Although this is an excellent resource in considering potential options, knowledge of both the options and the related benefits and pitfalls of each flap is important. Because prior surgery in the area may have compromised some of the reconstructive options, these algorithms clearly serve only as guidelines. Optimally, the major goals of reconstruction must be addressed; these goals include reestablishment of oral competence, adequate oral aperture and motion, and normal anatomic proportions.

Anatomic considerations, including blood supply, sensation, muscular function, motor innervation, and the topographic subunits, are critical concepts that must be recognized if optimal results are to be achieved.

The lips in repose approximate a hexagon with superior, inferior, and paired superolateral and inferolateral borders. The superior border is the inferior margin of the nose. The superolateral boundaries orient from around the alar sulci to the modioli. The inferolateral boundaries extend downward and medially from the modioli to the mentolabial sulcus.

The junction between external hair-bearing skin and the red hairless surface in the upper lip takes the form of a double-curved Cupid bow, the bilateral apices of which correspond to the lower end of each philtral ridge. The depth of the skin–red lip junction of the lower lip varies greatly in individuals, but invariably some inferomedially directed convexity from the modioli is present.

The glistening, pink, and moist appearance of the free red lip, or vermillion, is due to its covering with a specialized stratified squamous epithelium that is thinnest near the white skin and increases in thickness slightly as the mucosa is approached. The epithelium is grooved with abundant long dermal papillae that carry a rich capillary plexus and sensory innervation, which account for the red lip's characteristic color and high discriminative sensitivity.

Previously, the oral fissure was assumed to be surrounded by a series of complete ellipses of muscle resulting in a sphincter compression of the lip margins. Upon further functional inspection, independent quadrants clearly are apparent. Each quadrant consists of a pars peripheralis and a smaller pars marginalis. The pars marginalis is not limited solely to the vermilion but extends outward. The pars marginalis is located anterior and superior to the most distal portion of pars peripheralis except at the mouth corner where it is located just anterior and inferior to the most distal portion of pars peripheralis, and anterior to the bundle of buccinator muscle.[2]

Formally, the orbicularis oris muscle as a whole is composed of 8 segments, each representing a fan with its stem at the modiolus. The region of opposition of marginal and peripheral parts is indicated by the red-white junction ventrally, and the mucosal-red lip junction posteriorly. Accessory muscles of the orbicularis oris complex exist and mainly consist of superior and inferior tractors. Superiorly, these tractors are the zygomaticus minor, the levator labii superioris, and the levator labii superioris alaeque nasi. The depressor labii inferioris and the platysmal pars labialis are the inferior tractors.

Motor innervation is derived from the facial nerve branches. All mentioned muscles receive their neural innervation from the posterior aspect of the facial nerve. The blood supply is derived from superior and inferior labial arteries, which branch from the facial artery superomedially. The mental nerves inferiorly and the supraorbital nerves superiorly provide sensation.

Do not perform closure of any defect after neoplastic excision until margins have been adequately examined. Proceeding with a complex closure prior to establishment of adequate margins can certainly compromise the ultimate result. Soft tissues containing neoplastic cells may be undermined and relocated, ultimately confusing further excision.

Previous operations with possible compromise of labial vessels may be a contraindication to the use of a pedicled labial flap. Therefore, a complete history is essential.

The laboratory tests that are required for lip reconstruction are those that would be necessary in any type of surgical intervention. Evaluation of coagulation profile, blood counts, blood chemistry, electrocardiography, chest radiography, and other specialized cardiac and pulmonary tests are indicated as appropriate for the age and medical conditions of each patient.

See the list below:

• Most cases of primary lip reconstruction do not require special imaging. If any possibility exists that the underlying mandible is involved with a lower lip neoplasm, CT scanning with bony windows is indicated.

• Consider MRI in those patients who present with preoperative hypoesthesia of the upper or lower lip. In this case, suspicion of infraorbital or submental nerve infiltration may be warranted. Extent of infiltration can certainly have an impact on the choice of extirpative technique.

Diagnostic confirmation of cancer is often prudent prior to any extensive resection. Various biopsy techniques are available.

Because no surgical defect is the same, an individualized approach must be anticipated. General guidelines exist to help in the classification of defects according to depth and location. Such simplified categorization has its limitations but is quite instrumental in providing an organized approach to this highly variable problem.

In this section, superficial and full-thickness defects are discussed separately because the treatment options vary substantially.

Superficial defects of the upper lip

Most upper lip reconstructions involve the perioral skin rather than the vermilion or red lip because basal cell carcinoma is overwhelmingly the predominant pathology. Because of the lack of excess skin in the areas between the lip and nose, many reconstructions for this area use medial cheek advancement. Superficial defects of the lateral upper lip may be closed primarily in harmony with the relaxed skin tension lines. Defects closer to the nasolabial sulcus may be closed primarily within this fold. Small defects in those lateral subunits may also be amenable to an A-T closure using incisions at the vermilion border or medial cheek advancement. Larger superficial defects of the lateral upper lip may require excision of the entire subunit. In patients with adequate cheek laxity, an inferiorly based nasolabial flap may provide coverage of the entire lateral upper lip.

In the less-common circumstance of superficial defects of the red lip with remaining orbicularis, full-thickness grafting or healing by secondary intention is most appropriate because any advancement in this region usually results in untoward distortion of the upper lip projection. The donor site for red lip defects is the buccal surface of the red lip at a separate site. The donor site can be left to heal by secondary intention. Superficial defects within the philtral subunit may also be allowed to close by secondary intention or by full-thickness skin grafting typically from the periauricular region.

Superficial defects of the lower lip

A variety of techniques are important in the management of lower lip defects. Very common problems encountered in the lower lip are leukoplakia and actinic cheilitis. These conditions are often observed in association with squamous cell carcinomas. For this reason, lip shave or superficial excision, including vermilionectomy, of such damaged mucosa is commonly employed. Buccal mucosa can be undermined sharply and bluntly to allow advancement to the previous red-white junction. Occasionally, such defects are too large to allow undermining alone, and a pedicled flap must be used. The ventral surface of the anterior tongue is a dependable location. Flap division requires a separate procedure and can be performed 2 weeks after the initial procedure. Smaller partial-thickness defects can often be allowed to heal secondarily, or buccal surface grafts can be harvested from a separate site and used for a full-thickness graft.

Similar to the upper lip, common adjuncts include A-T flaps with relaxing incisions either at the vermilion border or at the labiomental crease.

Full-thickness defects

Deeper facial defects often require a wide variety of flap techniques to optimize closure. A brief discussion of the more widely used tissue transfer techniques precedes discussion of the approach and philosophy to closure based on location.

In 1898, Abbe first described the lip switch flap (Abbe flap), which was originally designated as a complete philtral reconstruction for the relief of the bilateral cleft lip deformity. The use of this flap has been liberalized, and today it is quite useful and a versatile means of both lower and upper lip reconstructions. The flap can be taken from either lip, and its shape and size are dependent on the defect. Typically, a flap half the size of the defect is adequate because the change of length of both lips is symmetric. The flap is incised full thickness with care at the vermilion border of one side to leave it pedicled on a small amount of mucosa and the labial artery. A meticulous 3-layer closure at both the donor and recipient sites is standard. Two stages are required because the pedicle must be ligated and inset at approximately 3 weeks after the principle procedure.

For those defects that extend laterally to include the oral commissure, the Estlander flap (lateral lip switch flap) is a useful procedure. This is a lip switch technique similar to the Abbe flap and typically uses a medially based full-thickness upper lip. Oral continence results are excellent, although a second stage often is necessary to correct the typical rounding at the new commissure. This second-stage commissuroplasty is typically performed 12 weeks after the initial procedure and includes a triangular incision laterally at the modiolus. The red lip extending to the lower lip is elevated superficially and used to repair the upper lip laterally. Buccal mucosa is elevated inferiorly and advanced externally to close the remaining lower lip defect at the oral commissure.

In a 1974 report, Karapandzic describes the standard procedure that functionally reconstructs large defects of both the upper and lower lips.[1] This method is based on the principle that the best form of reconstruction comes from tissue that most closely resembles the tissue being replaced—in this case, the lip and cheek. Musculocutaneous flaps with a width equal to the height of the defect are formed on both sides of the defect. The neurovascular supply to the orbicularis oris musculature, namely the facial artery and facial nerve branches, are dissected out and spared. A gradual cutting of the peripheral muscle fibers and concentric undermining allows advancement without the need to extend within the mucosa. Because only the peripheral rim of orbicularis oris muscle is incised, and the buccinator muscle is preserved, complete and immediate function is restored.

The nasolabial fold provides color- and texture-matched tissue to the upper and lower lips. An excellent blood supply based on the facial arteries and a natural-appearing scar at the donor site reinforces this flap as a useful adjunct in lip reconstruction. Most flaps for this purpose are based inferiorly and may include myocutaneous or cutaneous donor layers. The Gate flap is essentially a larger, innervated, inferiorly based, myocutaneous nasolabial flap that can be used for unilateral or bilateral closure of defects of the entire lower lip if needed. Motor function is not quite as automatic as in the Karapandzic flap, but donor tissue is more abundant. Therefore, this flap is a useful option in cases that are limited by significant microstomia and by limited oral access when a Karapandzic flap is used.

A study by Gonzalez and Etchichury indicated that combining standard Karapandzic and Abbe flaps is an effective means of repairing large lower lip defects following Mohs surgery. The investigators stated that although Karapandzic flap repair can provide consistent outcomes functionally and aesthetically, its use in large defects may cause the upper and lower lips to be disproportionate and can blunt the commissures. The Abbe flap, however, can be used to balance the lips and prevent rounding of the commissures. The study involved five patients who, after undergoing Mohs surgery for lower lip skin cancer, had defects of up to 80%. Reconstruction with the Karapandzic/Abbe flap combination resulted in very good to excellent aesthetic outcomes in four patients and a good aesthetic result in one patient, although mild microstomia occurred in one case. Function was maintained in all patients. The investigators cautioned, however, that owing to the risk of microstomia, other flap combinations offer a more favorable approach than the standard Karapandzic/Abbe flap combination in defects of over 80%.[3]

Perialar crescentic cheek excision is a useful technique for defects of the upper lip that require musculocutaneous advancement from adjacent cheek tissue. Simple advancement would cause bunching at the perialar folds. This excision is essentially an elliptical excision with the upper part shifted laterally to avoid the nostril. The perialar skin may be preserved as a caudally based flap to reconstruct columellar or nostril floor defects.

A variety of donor sites have been described for use in lip reconstruction. These sites are based on the size and nature of the lip defect and associated surrounding facial structures. Consider microvascular free tissue transfer techniques in situations in which the protocols outlined below are not adequate.

Full-thickness defects of the upper lip

Defects of up to one third of the upper lip, not including the majority of the philtral subunit, may be closed primarily without risk of significant tightening. Often this closure also requires a perialar excision and advancement. Meticulous realignment of the vermilion border is paramount.

Full-thickness defects that involve a majority of the philtral subunit are treated very effectively with replacement of the entire philtral subunit. An Abbe flap from the lower lip can adequately reconstruct the central subunit, and depending on the size of the residual lateral subunit defects, these defects can often be closed with careful approximation to the Abbe flap. Precisely scratching or tattooing the red-white border prior to excision can facilitate alignment of the vermilion border.

For full-thickness defects that include greater than one half of the upper lip, an inclusion of more than 1 subunit is necessary. Using the above-mentioned techniques in combination, nearly all but the largest defects are amenable to closure. For example, a defect including the central subunit and most of a lateral or both lateral subunits can be reconstructed employing advancement flaps for the lateral subunits and a central Abbe flap for philtral reconstruction.

With care to align the flaps in a position approximating the philtrum, natural appearing contours are possible. Excision of excess perialar skin in a crescentic fashion is necessary to avoid blunting in this area. Initial alignment of the philtral reconstruction as a means of orientation ensures that the philtrum is centrally located in relation to the nasal columella. The initial alignment also ensures that adequate advancement of the lateral subunits can be performed without risk of excess tension on this central reconstruction, with resultant lateral deviation and an awkward appearing upper lip.

Although rare, full-thickness defects of the entire upper lip can be a serious challenge. Bilateral nasolabial flaps may be used for the lateral subunits, and an Abbe flap may be used for the central subunit in patients with adequate cheek laxity. Advancement of labial mucosa onto the skin flaps recreates a red lip subunit. Another option in patients with less skin laxity is the Karapandzic flap using a reverse elevation. While effective in closing such challenging defects, microstomia can be problematic.

Full-thickness defects of the lower lip

V-excision with primary closure is considered adequate in most full-thickness defects encompassing up to one third of the lower lip. The vermilion border must be realigned meticulously to avoid malalignment. A 3-layer closure, including the oral mucosa, the orbicularis oris muscle, and the overlying skin in individual layers, generally is necessary for full-thickness reconstruction. A W-shaped excision may be used to avoid crossing the mentolabial crease and to allow for even larger defects to be closed primarily.

For larger centrally located defects in which closure certainly affects the mentolabial crease, bilateral advancement flap (double-barrel) closures allow adequate undermining in cases of defects up to three fourths of the lower lip. Another option for larger defects laterally located, but not including the oral commissure, is the Abbe flap. As previously discussed, the upper lip donor site should be approximately one half of the size of the defect. For defects that include the oral commissure, the Estlander flap often is an excellent option. Because this flap generally causes rounding of the oral commissure, a secondary commissuroplasty procedure is usually necessary at a separate time.

A fan flap, first described by Gillies and popularized by Millard, is another option.[4] This flap has a superiorly based pedicle that provides additional tissue to the lip so that microstomia is avoided. Because of the reorientation of the orbicularis oris muscle, a lack of motor function and minimal return of sensation results in this portion of the flap. Buccal advancement is often necessary to recreate the border between the vermilion and the red and white portions of the lip.

The Karapandzic flap is an excellent 1-stage option for innervated and well-vascularized closure of defects of one half of the upper lip or larger. However, the significant limitation of this flap is microstomia. For patients in whom oral access is not sufficient to use this type of reconstruction, other options are available. Bilateral Gillies fan flaps result in adequate coverage for defects of varying thickness, even for full defects. Because of the reorientation of the muscle and orientation of tissue transfer, motor function and sensitivity of the flap are limited. Advancement of buccal mucosa to the advanced skin is often necessary to recreate a red-white border.

Bernard and Von Burow popularized the bilateral cheek advancement flap, which is another option for total lip defects. Webster later modified this technique. In this reconstruction, large cheek advancement flaps are designed, with excess advanced skin oriented within the nasolabial folds superiorly and in the crease between the mentum and the cheek inferiorly. Advancement of buccal mucosa is necessary for creation of a new vermilion. Because denervation is necessary to advance the cheek musculature, a lack of motor function and sensitivity results, which limits this type of tissue transfer.

A prospective study by Denadai et al indicated that a modified Bernard-Webster flap can effectively repair full-thickness lower lip defects produced by squamous cell carcinoma excisions and covering more than one third of the lower lip’s length. Ten of the study’s 12 patients had no complications, with the other two experiencing wound dehiscence. Although transient and permanent functional abnormalities were encountered in recent and late postoperative assessments of 10 patients, 10 patients reported their late functional results to be satisfactory.[5]

Okochi et al described the use of a modified Bernard technique called the hemi-Bernard method, for unilateral, full-thickness lower lip reconstruction following malignant tumor resection. The technique, performed on three patients in the study, allowed retention of orbicularis oris muscle movement and extension of lower lip length.[6]

A study by Ayhan et al indicated that sensory recovery can be expected in noninnervated flaps used in total lower lip reconstruction and that this recovery is influenced by factors such as patient age and the type of flap used. In the study, sensory recovery was found to be more likely with the use of fasciocutaneous free flaps than with musculocutaneous flaps. The investigators also found that the flap’s ability to regain the sense of touch (including two-point discrimination) and temperature perception were related to the age of the patient, whether he or she smoked, and whether the patient had undergone radiation treatment. Ayhan and colleagues concluded that noninnervated flaps should attain “reasonable” sensory recovery if the patient is relatively young, if the recipient bed has enough surface contact area and is free of marked scarring, and if the major sensory nerve in that area has been retained.[7]

Discussion of risks and alternatives is a fundamental part of informed consent prior to any surgical procedure; lip reconstruction is no exception. Because the exact reconstructive option is not often known at the onset of the procedure, the above guidelines allow an organized discussion of the possibilities.

These details have been highlighted in the discussion of each reconstructive option (see Surgical therapy). In the cases of multilayered closure, general guidelines for the choice of suture material are worthy of mention. Mucosa is typically closed with a faster self-absorbing suture such as chromic suture. Muscle layers are better approximated with a longer lasting nonreactive material. Polydioxanone (PDS) fulfills these criteria. The skin is optimally addressed with a nonresorbable nonreactive monofilament, such as nylon or Prolene.

Routine surgical wound care includes regular cleaning of suture lines to minimize crust formation. Hydrogen peroxide solution is helpful for atraumatic removal. Antibiotic ointment is generally used in all nonmucosal sites for the first 48 hours, after which benefits of the antibiotic are not clear.

Optimal wound closure excludes tension at the suture lines. For this reason, sutures can be removed from 4-7 days postoperatively. Adjunctive means of minimizing tension at the suture sites include Steri-strips and layered closure.

Secondary procedures are generally timed on an individual basis. In general, pedicle insets in the case of lip switch techniques can be performed at approximately 3 weeks following the initial operation.

Revision and secondary commissuroplasty procedures are best performed when most of the healing and postoperative edema is completed, usually after a minimum of 3 months.

Given the relatively generous vascular supply of most head and neck structures, including the perioral region, postoperative infectious complications involving the lips and oral commissure are uncommon. Flap necrosis may sometimes follow inadvertent kinking or ligation of the labial artery during lip switch procedures; therefore, meticulous handling of the tissues is warranted. Often the hypoesthesia of the donor and recipient sites warrants frequent reminding; therefore, instruct the patient to avoid aggressive opening of the mouth and to take care while eating in order to minimize pedicle trauma in the postoperative period.

Recurrent disease is another unfortunate complication of any oncologic procedure. Use frozen section pathology or Mohs techniques judiciously in order to minimize the incidence of recurrence.

A retrospective study by Sanniec et al, of 615 cases of lip reconstruction following Mohs cancer excision, found the complication rate to be 10.2%. Linear closure or V-wedge excision and closure was employed in a significant majority of defects. Complications included oral incompetence and cancer recurrence. However, complication rates were not found to differ significantly from the overall cohort in patients over age 75 years, smokers, or individuals on anticoagulation therapy. Most defects involved the upper lateral lip, with 40.2% of the study’s defects including both the skin and vermilion.[8]

In a study by Madorsky and Meltzer, postoperative photographs of 18 patients who underwent myomucosal lip island flap reconstruction for small to medium-sized lower lip defects revealed mild vermilion inferior retraction in four cases (22%), mild contour irregularity in one case (6%), and a visible white scar in the red lip in one case. The technique was judged an effective reconstruction method by the investigators.[9]

A literature review by Nicholas et al looking at a range of flaps for oncologic reconstruction of the upper cutaneous lip found the rate of complications, including infection, hemorrhage/hematoma, wound dehiscence, and flap necrosis, to range between 0% and 7.69%. Among all of the flaps considered, which consisted of V-Y advancement, ergotrid, rotation, Karapandzic, alar crescent, and propeller facial artery perforator flaps, the Karapandzic flap was associated with the worst functional outcomes with regard to salivary continence, microstomia, and paresthesia. The V-Y advancement flap was the flap most associated with poor scarring (0%-20%) and the need for revision surgery (0%-46.7%).[10]